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Ribeiro SA, Braga EL, Queiroga ML, Clementino MA, Fonseca XM, Belém MO, Magalhães LM, de Sousa JK, de Freitas TM, Veras HN, de Aquino CC, Santos AD, de Moura FR, Dos Santos AA, Havt A, Maciel BL, Lima AA. A New Murine Undernutrition Model Based on Complementary Feeding of Undernourished Children Causes Damage to the Morphofunctional Intestinal Epithelium Barrier. J Nutr 2024; 154:1232-1251. [PMID: 38346539 DOI: 10.1016/j.tjnut.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/26/2024] [Accepted: 02/01/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Complementary feeding is critical in establishing undernutrition. However, experimental undernourished diets do not represent the amount of nutrients in the complementary diets of undernourished children. OBJECTIVES To develop, validate, and evaluate the impact of a new murine model of undernutrition on the intestinal epithelium, based on the complementary diet of undernourished children from 7 countries with low-socioeconomic power belonging to the Malnutrition-Enteric Diseases (MAL-ED) cohort study. METHODS We used the difference in the percentage of energy, macronutrients, fiber and zinc in the complementary diet of children without undernutrition compared with stunting (height-for-age Z-score < -2) for the MAL-ED diet formulation. Subsequently, C57BL/6 mice were fed a control diet (AIN-93M diet) or MAL-ED diet for 28 d. Weight was measured daily; body composition was measured every 7 d; lactulose:mannitol ratio (LM) and morphometry were evaluated on days 7 and 28; the cotransport test and analysis of intestinal transporters and tight junctions were performed on day 7. RESULTS The MAL-ED diet presented -8.03% energy, -37.46% protein, -24.20% lipid, -10.83% zinc, +5.93% carbohydrate, and +45.17% fiber compared with the control diet. This diet rapidly reduced weight gain and compromised body growth and energy reserves during the chronic period (P < 0.05). In the intestinal epithelial barrier, this diet caused an increase in the LM (P < 0.001) and reduced (P < 0.001) the villous area associated with an increase in FAT/CD36 in the acute period and increased (P < 0.001) mannitol excretion in the chronic period. CONCLUSIONS The MAL-ED diet induced undernutrition in mice, resulting in acute damage to the integrity of the intestinal epithelial barrier and a subsequent increase in the intestinal area during the chronic period. This study introduces the first murine model of undernutrition for the complementary feeding phase, based on data from undernourished children in 7 different countries.
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Affiliation(s)
- Samilly A Ribeiro
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil.
| | - Enock Lr Braga
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Marcus L Queiroga
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Marco A Clementino
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Xhaulla Mqc Fonseca
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Mônica O Belém
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Lyvia Mvc Magalhães
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - José K de Sousa
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Thiago M de Freitas
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Herlice N Veras
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Cristiane C de Aquino
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Alan Dc Santos
- Núcleo de Estudos Químicos de Micromoléculas da Amazônia (NEQUIMA), Manaus, Brazil
| | - Flávio Rm de Moura
- Núcleo de Estudos Químicos de Micromoléculas da Amazônia (NEQUIMA), Manaus, Brazil
| | - Armênio A Dos Santos
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Alexandre Havt
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
| | - Bruna Ll Maciel
- Nutrition Postgraduation Program, Department of Nutrition, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Aldo Am Lima
- Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceará, Fortaleza, Brazil
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2
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Allison SP, Lobo DN. The clinical significance of hypoalbuminaemia. Clin Nutr 2024; 43:909-914. [PMID: 38394971 DOI: 10.1016/j.clnu.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 02/25/2024]
Abstract
Albumin is a relatively small molecule with a radius of 7.5 nm and a molecular weight of 65 kDa. It is the most abundant protein in plasma, accounting for 60-75% of its oncotic pressure. Its concentration in plasma is merely one static measurement reflecting a dynamic and complex system of albumin physiology, and is the net result of several different processes, one or more of which may become deranged by disease or its treatment. It is also unsurprising that hypoalbuminaemia has proved to be an indicator of morbidity and mortality risk since the underlying conditions which cause it, including protein energy malnutrition, crystalloid overload, inflammation, and liver dysfunction are themselves risk factors. In some cases, its underlying cause may require treatment but mostly it is just a parameter to be monitored and used as one measure of clinical progress or deterioration. While malnutrition, associated with a low protein intake, may be a contributory cause of hypoalbuminaemia, in the absence of inflammation and/or dilution with crystalloid its development in response to malnutrition alone is slow compared with the rapid change caused by inflammatory redistribution or dilution with crystalloids. Other significant causes include liver dysfunction and serous losses. These causal factors may occur singly or in combination in any particular case. Treatment is that of the underlying causes and associated conditions such as a low plasma volume, not of hypoalbuminaemia per se.
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Affiliation(s)
- Simon P Allison
- Formerly Professor in Clinical Nutrition, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, Division of Translational Medical Sciences, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK; Division of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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3
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Sturgeon JP, Njunge JM, Bourke CD, Gonzales GB, Robertson RC, Bwakura-Dangarembizi M, Berkley JA, Kelly P, Prendergast AJ. Inflammation: the driver of poor outcomes among children with severe acute malnutrition? Nutr Rev 2023; 81:1636-1652. [PMID: 36977352 PMCID: PMC10639108 DOI: 10.1093/nutrit/nuad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
Severe acute malnutrition (SAM) is the most life-threatening form of undernutrition and underlies at least 10% of all deaths among children younger than 5 years in low-income countries. SAM is a complex, multisystem disease, with physiological perturbations observed in conjunction with the loss of lean mass, including structural and functional changes in many organ systems. Despite the high mortality burden, predominantly due to infections, the underlying pathogenic pathways remain poorly understood. Intestinal and systemic inflammation is heightened in children with SAM. Chronic inflammation and its consequent immunomodulation may explain the increased morbidity and mortality from infections in children with SAM, both during hospitalization and in the longer term after discharge. Recognition of the role of inflammation in SAM is critical in considering new therapeutic targets in this disease, which has not seen a transformational approach to treatment for several decades. This review highlights the central role of inflammation in the wide-ranging pathophysiology of SAM, as well as identifying potential interventions that have biological plausibility based on evidence from other inflammatory syndromes.
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Affiliation(s)
- Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | - James M Njunge
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Claire D Bourke
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Gerard Bryan Gonzales
- Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Ruairi C Robertson
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | | | - James A Berkley
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Paul Kelly
- is with the Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
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4
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da Silva Goncalves dos Santos J, de Farias Meirelles B, de Souza da Costa Brum I, Zanchetta M, Xerem B, Braga L, Haiut M, Lanziani R, Musa TH, Cordovil K. First Clinical Nutrition Outpatient Consultation: A Review of Basic Principles in Nutritional Care of Adults with Hematologic Disease. ScientificWorldJournal 2023; 2023:9303798. [PMID: 37780637 PMCID: PMC10539097 DOI: 10.1155/2023/9303798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/11/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Methods A bibliographic survey was carried out between 2020 and 2022 using two databases: PubMed/MEDLINE and Scientific Electronic Library Online (SciELO) and the information source Academic Google, irrespective of language or geography. Results In the first nutrition consultation (FNC), there should be an investigative direction focused on nutritional interventions in the short, medium, and long term. The record in the patient's medical record is relevant for carrying out the consultation, according to the recommendations of the normative councils of medicine and nutrition. The main steps to be followed are the investigation of the presence of food allergies and intolerances; the drugs/nutritional supplements in use; changes in the digestive tract; the presence or absence of picamalacia; and socioeconomic and lifestyle data. In addition, it is necessary to carry out laboratory evaluations, semiological assessment, anthropometric assessment, and assessment of food consumption. In the end, the nutritional approach should be composed of calculation of energy and macronutrient and micronutrient needs, intervention in nutritional status deviations, nutritional guidelines, and nutritional therapeutic planning of return, focusing on adherence to treatment. Conclusion The first nutrition consultation may represent investigative steps that help the clinical nutritionist in the management, allowing a longitudinal and specific nutritional therapeutic planning for patients assisted in large reference centers for hematological disease.
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Affiliation(s)
- Julia da Silva Goncalves dos Santos
- Institute of Hematology Arthur Siqueira Cavalcanti (Hemorio), Rio de Janeiro, RJ, Brazil
- Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | | | - Isabela de Souza da Costa Brum
- Institute of Hematology Arthur Siqueira Cavalcanti (Hemorio), Rio de Janeiro, RJ, Brazil
- Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
| | - Mariana Zanchetta
- Institute of Hematology Arthur Siqueira Cavalcanti (Hemorio), Rio de Janeiro, RJ, Brazil
| | - Bruna Xerem
- Institute of Hematology Arthur Siqueira Cavalcanti (Hemorio), Rio de Janeiro, RJ, Brazil
| | - Lucas Braga
- Institute of Hematology Arthur Siqueira Cavalcanti (Hemorio), Rio de Janeiro, RJ, Brazil
| | - Marcia Haiut
- Institute of Hematology Arthur Siqueira Cavalcanti (Hemorio), Rio de Janeiro, RJ, Brazil
| | - Renata Lanziani
- Institute of Hematology Arthur Siqueira Cavalcanti (Hemorio), Rio de Janeiro, RJ, Brazil
| | - Taha Hussein Musa
- Biomedical Research Institute, Darfur University College, Nyala, Sudan
| | - Karen Cordovil
- Institute of Hematology Arthur Siqueira Cavalcanti (Hemorio), Rio de Janeiro, RJ, Brazil
- Oswaldo Cruz Foundation (Fiocruz), Rio de Janeiro, RJ, Brazil
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Babatola AO, Ige JT, Adeniyi AT, Abidoye IA, Joseph O, Olorunfunmi J, Ilori BF, Komolafe AK, Olatunya OS. Anasarca as a manifestation of childhood volvulus: Diagnostic and management challenges in an 11-year old Nigerian boy. CASPIAN JOURNAL OF INTERNAL MEDICINE 2023; 14:138-142. [PMID: 36741491 PMCID: PMC9878898 DOI: 10.22088/cjim.14.1.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 02/05/2021] [Accepted: 12/06/2021] [Indexed: 02/07/2023]
Abstract
Background Small intestine volvulus occurs more commonly among younger children. It often poses diagnostic challenges when it occurs in older children and adults. For good clinical outcomes, it is essential to have prompt presentation, diagnosis and early intervention. Anasarca is not a common clinical manifestation of small intestine volvulus. Case Presentation We report this unusual presentation of small intestine volvulus in an 11-year old Nigerian boy who first presented only with anasarca. While being investigated for the cause of the anasarca, he developed features of acute abdomen thought to be spontaneous bacteria peritonitis initially. He had surgery where the diagnosis of small intestine volvulus was made. Conclusion The diagnosis and management of both anasarca and small intestine volvulus could be fraught with challenges. It is possible that anasarca can be the first manifestation of small intestine volvulus.
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Affiliation(s)
- Adefunke Olarinre Babatola
- Department of Pediatrics and Child Health, Ekiti State University Teaching Hospital, Ado Ekiti, Ekiti State, Nigeria,Correspondence: Adefunke Olarinre Babatola, Department of Pediatrics and Child Health, Ekiti State University Teaching Hospital, Ado Ekiti, Ekiti State, Nigeria. E-mail: , Tel: +2348035682315
| | - Joshua Taye Ige
- Department of Surgery, Ekiti State University Teaching Hospital, Ado Ekiti, Ekiti State, Nigeria
| | - Adewuyi Temidayo Adeniyi
- Department of Pediatrics and Child Health, Ekiti State University Teaching Hospital, Ado Ekiti, Ekiti State, Nigeria
| | - Ibukun Anuoluwa Abidoye
- Department of Radiology, Afe Babalola University/Multisystem Hospital, Ado Ekiti, Ekiti State, Nigeria
| | - Olarewaju Joseph
- Department of Surgery, Ekiti State University Teaching Hospital, Ado Ekiti, Ekiti State, Nigeria
| | - Joshua Olorunfunmi
- Department of Surgery, Ekiti State University Teaching Hospital, Ado Ekiti, Ekiti State, Nigeria
| | - Benjamin Folorunsho Ilori
- Department of Pediatrics and Child Health, Ekiti State University Teaching Hospital, Ado Ekiti, Ekiti State, Nigeria
| | - Akinwumi Kolawole Komolafe
- Department of Pediatrics and Child Health, Ekiti State University Teaching Hospital, Ado Ekiti, Ekiti State, Nigeria
| | - Oladele Simeon Olatunya
- Department of Pediatrics and Child Health, Ekiti State University Teaching Hospital, Ado Ekiti, Ekiti State, Nigeria
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Briend A. Kwashiorkor – New evidence in the puzzle of oedema formation. EBioMedicine 2022; 80:104070. [PMID: 35598438 PMCID: PMC9126987 DOI: 10.1016/j.ebiom.2022.104070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/06/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Frederiksberg, Denmark; Center for Child Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
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Gonzales GB, Njunge JM, Gichuki BM, Wen B, Ngari M, Potani I, Thitiri J, Laukens D, Voskuijl W, Bandsma R, Vanmassenhove J, Berkley JA. The role of albumin and the extracellular matrix on the pathophysiology of oedema formation in severe malnutrition. EBioMedicine 2022; 79:103991. [PMID: 35398787 PMCID: PMC9014367 DOI: 10.1016/j.ebiom.2022.103991] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND While fluid flows in a steady state from plasma, through interstitium, and into the lymph compartment, altered fluid distribution and oedema can result from abnormal Starling's forces, increased endothelial permeability or impaired lymphatic drainage. The mechanism of oedema formation, especially the primary role of hypoalbuminaemia, remains controversial. Here, we explored the roles of albumin and albumin-independent mechanisms in oedema formation among children with severe malnutrition (SM). METHODS We performed secondary analysis of data obtained from two independent clinical trials in Malawi and Kenya (NCT02246296 and NCT00934492). We then used an unconventional strategy of comparing children with kwashiorkor and marasmus by matching (discovery cohort, n = 144) and normalising (validation cohort, n = 98, 2 time points) for serum albumin. Untargeted proteomics was used in the discovery cohort to determine plausible albumin-independent mechanisms associated with oedema, which was validated using enzyme-linked immunosorbent assay and multiplex assays in the validation cohort. FINDINGS We demonstrated that low serum albumin is necessary but not sufficient to develop oedema in SM. We further found that markers of extracellular matrix (ECM) degradation rather than markers of EG degradation distinguished oedematous and non-oedematous children with SM. INTERPRETATION Our results show that oedema formation has both albumin-dependent and independent mechanisms. ECM integrity appears to have a greater role in oedema formation than EG shedding in SM. FUNDING Research Foundation Flanders (FWO), Thrasher Foundation (15122 and 9403), VLIR-UOS-Ghent University Global Minds Fund, Bill & Melinda Gates Foundation (OPP1131320), MRC/DfID/Wellcome Trust Global Health Trials Scheme (MR/M007367/1), Canadian Institutes of Health Research (156307), Wellcome Trust (WT083579MA).
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Affiliation(s)
- Gerard Bryan Gonzales
- Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, the Netherland,Department of Internal Medicine and Paediatrics, Laboratory of Gastroenterology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium,VIB-UGent Center for Inflammation Research, Ghent, Belgium,Corresponding author at: Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, the Netherland.
| | - James M. Njunge
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya,Corresponding author at: The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya.
| | - Bonface M Gichuki
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Bijun Wen
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Moses Ngari
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Isabel Potani
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada,Kamuzu University of Health Sciences (Former College of Medicine), Blantyre, Malawi
| | - Johnstone Thitiri
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Debby Laukens
- Department of Internal Medicine and Paediatrics, Laboratory of Gastroenterology, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium,VIB-UGent Center for Inflammation Research, Ghent, Belgium
| | - Wieger Voskuijl
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,Kamuzu University of Health Sciences (Former College of Medicine), Blantyre, Malawi,Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, the Netherland,Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, the Netherland
| | - Robert Bandsma
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Canada,Kamuzu University of Health Sciences (Former College of Medicine), Blantyre, Malawi
| | - Jill Vanmassenhove
- Department of Internal Medicine and Paediatrics, Renal Division, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - James A Berkley
- The Childhood Acute Illness & Nutrition (CHAIN) Network, Nairobi, Kenya,KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya,Nuffield Department of Medicine, Centre for Tropical Medicine & Global Health, University of Oxford, Oxford, UK
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8
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Sivanesan P, Weerasinghe T, Nanayakkara K, Samaraweera S, Seneviratne J, Elsner P. [Infant with generalized edema and a skin rash]. Hautarzt 2021; 73:411-413. [PMID: 34328513 DOI: 10.1007/s00105-021-04870-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 11/27/2022]
Affiliation(s)
| | - Thulasi Weerasinghe
- Department of Dermatology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - Kavindra Nanayakkara
- Department of Dermatology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - Sriyani Samaraweera
- Department of Dermatology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - Jayamini Seneviratne
- Department of Dermatology, Lady Ridgeway Hospital for Children, Colombo, Sri Lanka
| | - Peter Elsner
- Klinik für Hautkrankheiten, Universitätsklinikum Jena, Erfurter Str. 35, 07743, Jena, Deutschland.
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Influence of Malnutrition on the Pharmacokinetics of Drugs Used in the Treatment of Poverty-Related Diseases: A Systematic Review. Clin Pharmacokinet 2021; 60:1149-1169. [PMID: 34060020 PMCID: PMC8545752 DOI: 10.1007/s40262-021-01031-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 11/06/2022]
Abstract
Background Patients affected by poverty-related infectious diseases (PRDs) are disproportionally affected by malnutrition. To optimize treatment of patients affected by PRDs, we aimed to assess the influence of malnutrition associated with PRDs on drug pharmacokinetics, by way of a systematic review. Methods A systematic review was performed on the effects of malnourishment on the pharmacokinetics of drugs to treat PRDs, including HIV, tuberculosis, malaria, and neglected tropical diseases. Results In 21/29 PRD drugs included in this review, pharmacokinetics were affected by malnutrition. Effects were heterogeneous, but trends were observed for specific classes of drugs and different types and degrees of malnutrition. Bioavailability of lumefantrine, sulfadoxine, pyrimethamine, lopinavir, and efavirenz was decreased in severely malnourished patients, but increased for the P-glycoprotein substrates abacavir, saquinavir, nevirapine, and ivermectin. Distribution volume was decreased for the lipophilic drugs isoniazid, chloroquine, and nevirapine, and the α1-acid glycoprotein-bound drugs quinine, rifabutin, and saquinavir. Distribution volume was increased for the hydrophilic drug streptomycin and the albumin-bound drugs rifampicin, lopinavir, and efavirenz. Drug elimination was decreased for isoniazid, chloroquine, quinine, zidovudine, saquinavir, and streptomycin, but increased for the albumin-bound drugs quinine, chloroquine, rifampicin, lopinavir, efavirenz, and ethambutol. Clinically relevant effects were mainly observed in severely malnourished and kwashiorkor patients. Conclusions Malnutrition-related effects on pharmacokinetics potentially affect treatment response, particularly for severe malnutrition or kwashiorkor. However, pharmacokinetic knowledge is lacking for specific populations, especially patients with neglected tropical diseases and severe malnutrition. To optimize treatment in these neglected subpopulations, adequate pharmacokinetic studies are needed, including severely malnourished or kwashiorkor patients. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01031-z.
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Mortality in relation to profiles of clinical features in Ghanaian severely undernourished children aged 0-59 months: an observational study. Br J Nutr 2021; 125:1157-1165. [PMID: 32873346 DOI: 10.1017/s0007114520003396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Severe acute malnutrition (SAM) is associated with a complex pattern of various clinical conditions. We investigated how risk factors cluster in children with SAM, the relationship between clusters of risk factors and mortality as well as length of stay in children with SAM. A prospective observational study design was used. Data were extracted from medical records of 601 infants and children aged 0-59 months admitted and treated for SAM in three Ghanaian referral hospital between June 2013 and June 2018. Among the 601 medical records extracted, ninety-nine died. Three clusters of medical features clearly emerged from data analyses. Firstly, an association was defined by eye signs, pallor, diarrhoea and vomiting with gastrointestinal infections and malaria. In this cluster, pallor and eye signs were related to 2- to 5-fold increased mortality risk. Secondly, HIV, oedema, fast pulse, respiratory infections and tuberculosis; among those features, HIV increased child mortality risk by 2-fold. Thirdly, shock, convulsions, dermatitis, cold hands and feet, weak pulse, urinary tract infections and irritability were clustered. Among those features, cold hands and feet, dermatitis, convulsions and shock increased child mortality risk in a range of 2- to 9-fold. Medical conditions and clinical signs in children diagnosed with SAM associate in patterns and are related to clinical outcomes.
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11
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Kim GN, Ho S, Saulino D, Liu X. Severe Protein-Calorie Malnutrition-Associated Hepatic Steatosis in a Woman Who Had Roux-en-Y Gastric Bypass for Morbid Obesity Thirteen Years Ago. Gastroenterology Res 2021; 14:129-137. [PMID: 34007356 PMCID: PMC8110236 DOI: 10.14740/gr1378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Guriel N Kim
- College of Public Health, University of Florida, Gainesville, FL 32610, USA
| | - Sam Ho
- Department of Pathology, Immunology, and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - David Saulino
- Department of Pathology, Immunology, and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
| | - Xiuli Liu
- Department of Pathology, Immunology, and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL 32610, USA
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12
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Custer A, Custer D, Shao P, Kirolos H. Secondary Kwashiorkor Disease in a Patient with Gastric Bypass Surgery and Short Gut Syndrome. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e928468. [PMID: 33536404 PMCID: PMC7871295 DOI: 10.12659/ajcr.928468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Kwashiorkor disease is a subtype of severe acute protein malnutrition characterized by peripheral edema associated with hypoalbuminemia and ascites. It can result from both protein deficiency and protein loss. In resource-poor countries, the disease often is caused by inadequate dietary intake, but in resource-rich countries, it can be seen as a rare complication of severe malabsorption. CASE REPORT We present the case of a 60-year-old woman who presented with 1 week of progressive anasarca in the setting of decreased dietary intake and poor tolerance of total parenteral nutrition (TPN). She had a history of Roux-en-Y gastric bypass surgery which was complicated by a strangulated internal hernia that required an exploratory laparotomy and small bowel resection. She subsequently developed short gut syndrome with TPN dependence. Work-up revealed hypoalbuminemia with several micronutrient deficiencies consistent with secondary kwashiorkor disease. With a multidisciplinary approach that included Gastroenterology, Pharmacy, and Nutrition, she was treated with albumin, furosemide, nutritional supplementation, and ultimately rechallenged with TPN. At discharge, her swelling had improved, her weight had decreased, and her albumin improved to the normal range. CONCLUSIONS This case is a unique presentation of secondary kwashiorkor disease. In our patient, the combination of gastric bypass surgery and short gut syndrome with poor TPN tolerance likely led to severe protein malabsorption. This underscores the importance of recognizing the signs and symptoms of kwashiorkor disease and understanding the associated complications so that treatment can be instituted promptly. Furthermore, the case demonstrates how an interdisciplinary approach to management can increase the chance of a successful outcome.
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Affiliation(s)
- Adam Custer
- Department of Internal Medicine and Pediatrics, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Dylan Custer
- Undergraduate Studies, Clarkson University, Potsdam, NY, USA
| | - Paul Shao
- Department of Internal Medicine and Pediatrics, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| | - Henry Kirolos
- Department of Internal Medicine and Pediatrics, University of California Los Angeles (UCLA), Los Angeles, CA, USA
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13
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Bunker S, Pandey J. Educational Case: Understanding Kwashiorkor and Marasmus: Disease Mechanisms and Pathologic Consequences. Acad Pathol 2021; 8:23742895211037027. [PMID: 34458565 PMCID: PMC8392804 DOI: 10.1177/23742895211037027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 06/20/2021] [Accepted: 07/06/2021] [Indexed: 11/17/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.1.
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Affiliation(s)
- Sarah Bunker
- Central Michigan University College of Medicine, East Campus Drive, Mount Pleasant, MI, USA
| | - Jyotsna Pandey
- Central Michigan University College of Medicine, East Campus Drive, Mount Pleasant, MI, USA
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Preidis GA, Soni KG, Suh JH, Halder T, Kim KH, Choi JM, Li F, Devaraj S, Conner ME, Coarfa C, Jung SY, Moore DD. Coagulopathy in Malnourished Mice Is Sexually Dimorphic and Regulated by Nutrient-Sensing Nuclear Receptors. Hepatol Commun 2020; 4:1835-1850. [PMID: 33305154 PMCID: PMC7706303 DOI: 10.1002/hep4.1622] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/28/2020] [Accepted: 09/18/2020] [Indexed: 11/23/2022] Open
Abstract
Liver dysfunction, including coagulopathy, is a prominent feature of protein-energy malnutrition. To identify mechanisms underlying malnutrition-associated coagulopathy, we administered a low-protein low-fat diet to lactating dams and examined hepatic transcription and plasma coagulation parameters in young adult weanlings. Malnutrition impacted body composition to a greater extent in male versus female mice. Transcriptional profiles suggested opposing effects of nutrient-sensing nuclear receptors, namely induction of peroxisome proliferator-activated receptor α (PPARα) targets and repression of farnesoid-X-receptor (FXR) targets. Coagulopathy with decreased synthesis of fibrinogen-α (FGA) and factor 11 (F11) was observed in malnourished male animals but not female animals. In primary mouse hepatocytes, FXR agonist increased and PPARα agonist decreased Fga and F11 messenger RNA expression. Nuclear receptor DNA response elements were identified in the Fga and F11 gene regulatory regions, and opposing effects of FXR and PPARα were confirmed with luciferase assays. Unexpectedly, hepatic PPARα protein was markedly depleted in malnourished male liver and was not enriched on Fga or F11 response elements. Rather, there was loss of FXR binding at these response elements. Reduced PPARα protein was associated with loss of hepatocyte peroxisomes, which are necessary for bile acid biosynthesis, and with decreased concentrations of bile acids that function as FXR ligands, most notably the FXR agonist chenodeoxycholic acid. Conclusion: Malnutrition impairs growth and liver synthetic function more severely in male mice than in female mice. Malnourished male mice are coagulopathic and exhibit decreased hepatocyte peroxisomes, FXR agonist bile acids, FXR binding on Fga and F11 gene regulatory elements, and coagulation factor synthesis. These effects are absent in female mice, which have low baseline levels of PPARα, suggesting that nutrient-sensing nuclear receptors regulate coagulation factor synthesis in response to host nutritional status in a sex-specific manner.
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Affiliation(s)
- Geoffrey A. Preidis
- Section of Gastroenterology, Hepatology & NutritionDepartment of PediatricsBaylor College of Medicine and Texas Children’s HospitalHoustonTXUSA
| | - Krishnakant G. Soni
- Section of Gastroenterology, Hepatology & NutritionDepartment of PediatricsBaylor College of Medicine and Texas Children’s HospitalHoustonTXUSA
| | - Ji Ho Suh
- Section of Gastroenterology, Hepatology & NutritionDepartment of PediatricsBaylor College of Medicine and Texas Children’s HospitalHoustonTXUSA
| | - Tripti Halder
- Section of Gastroenterology, Hepatology & NutritionDepartment of PediatricsBaylor College of Medicine and Texas Children’s HospitalHoustonTXUSA
| | - Kang Ho Kim
- Department of Molecular and Cellular BiologyBaylor College of MedicineHoustonTXUSA
| | - Jong Min Choi
- Advanced Technology CoreMass Spectrometry Proteomics CoreBaylor College of MedicineHoustonTXUSA
| | - Feng Li
- Department of Molecular and Cellular BiologyBaylor College of MedicineHoustonTXUSA
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTXUSA
| | - Sridevi Devaraj
- Department of Pathology and ImmunologyBaylor College of MedicineHoustonTXUSA
| | - Margaret E. Conner
- Department of Molecular Virology and MicrobiologyBaylor College of MedicineHoustonTXUSA
| | - Cristian Coarfa
- Department of Molecular and Cellular BiologyBaylor College of MedicineHoustonTXUSA
| | - Sung Yun Jung
- Department of Molecular and Cellular BiologyBaylor College of MedicineHoustonTXUSA
- Advanced Technology CoreMass Spectrometry Proteomics CoreBaylor College of MedicineHoustonTXUSA
- Verna and Marrs McLean Department of Biochemistry and Molecular BiologyBaylor College of MedicineHoustonTXUSA
| | - David D. Moore
- Department of Molecular and Cellular BiologyBaylor College of MedicineHoustonTXUSA
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15
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Janssen SL, Scholbach T, Jeno S, Laurie H, Meyer M, Combs C. Interprofessional Management of Median Arcuate Ligament Syndrome (Dunbar Syndrome) Related to Lumbar Lordosis and Hip Dysplasia: A Patient's Perspective. Eur J Case Rep Intern Med 2020; 7:001605. [PMID: 32665927 PMCID: PMC7350969 DOI: 10.12890/2020_001605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 03/11/2020] [Indexed: 11/16/2022] Open
Abstract
We present a 53-year-old female patient with median arcuate ligament syndrome (MALS), also known as Dunbar syndrome or celiac artery compression syndrome, related to lumbar lordosis and hip dysplasia. She utilized interprofessional management strategies, which were beneficial in reducing lumbar lordosis and MALS-related symptoms. This finding is important because there are no other reports in the literature describing interprofessional strategies to manage symptoms for patients who are waiting for surgery or are not candidates for surgery.
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Affiliation(s)
- Sclinda Lea Janssen
- Department of Occupational Therapy, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
| | | | - Susan Jeno
- Department of Physical Therapy, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
| | | | - Mandy Meyer
- Department of Occupational Therapy, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA.,Department of Biomedical Sciences, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
| | - Colin Combs
- Department of Biomedical Sciences, School of Medicine and Health Sciences, University of North Dakota, Grand Forks, ND, USA
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16
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Kamaruzaman NA, Jamani NA, Said AH. An infant with kwashiorkor: The forgotten disease. MALAYSIAN FAMILY PHYSICIAN : THE OFFICIAL JOURNAL OF THE ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA 2020; 15:46-49. [PMID: 32843945 PMCID: PMC7430309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Undernutrition remains a major public health concern, especially in developing countries. Despite being rich in resources, Malaysia is still home to children suffering from severe undernutrition. This paper presents the case of a 5-month-old boy with kwashiorkor stemming from improper weaning which was overlooked. This case highlights the importance of recognizing the early signs of kwashiorkor to allow for early referrals for proper management and prevent its possible complications.
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Affiliation(s)
- N A Kamaruzaman
- Department of Family Medicine, Kulliyyah of Medicine, International Islamic University Malaysia, Jalan Sultan Ahmad Shah, 25200 Kuantan Pahang, Malaysia
| | - N A Jamani
- Department of Family Medicine, Islamic University Malaysia, Jalan Sultan Ahmad Shah, 25200 Kuantan Pahang, Malaysia
| | - A H Said
- Department of Family Medicine, Kulliyyah of Medicine, International Islamic University Malaysia, Jalan Sultan Ahmad Shah, 25200 Kuantan Pahang, Malaysia
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17
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Nduhukire T, Atwine D, Rachel L, Byonanebye JE. Predictors of in-hospital mortality among under-five children with severe acute malnutrition in South-Western Uganda. PLoS One 2020; 15:e0234343. [PMID: 32589637 PMCID: PMC7319331 DOI: 10.1371/journal.pone.0234343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/23/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Severe acute malnutrition (SAM) affects about 13 million under-five children (U5), with an estimated one million dying every year. In this study we aimed at determining the in hospital mortality and its associated factors among U5s admitted with SAM. METHODS This was a prospective cohort study of children 6 months to 5 years with SAM admitted at Mbarara Regional Referral Hospital (MRRH) between June and August 2015. Care-takers were interviewed to collect socio-demographic and clinical information. Children under-went physical examination and had blood drawn for HIV, serum glucose, malaria, full blood count, culture and serum electrolytes investigation. Children were managed according to WHO treatment guidelines for SAM. All participants were followed up for a maximum period of 30 days. The proportion of U5 deaths within the first 48 hours and during the entire admission period was calculated. Using Poisson regression analysis, predictors of in-hospital mortality were analyzed with STATA/IC 11.0. RESULTS We enrolled 122 children, median age of 15 months [IQR:11-24], 58.2% males, 90% immunized, 81% ill for more than 2 weeks before admission, 71% from lower health facilities and majority with unknown HIV status(76%). Overall, 13 (10.7%) children died in hospital. Seven (5.7%) died within the first 48 hours. Intravenous (IV) fluid administration significantly predicted in-hospital mortality (adjusted IRR: 7.2, 95%CI: 2.14-24.08, p = 0.001). CONCLUSION The in-hospital mortality in U5s with SAM was lower than that previously reported in central Uganda. Intravenous fluid administration significantly predicted overall in-hospital mortality. While Administration of intravenous fluids is still the main stay of managing severely malnourished children with shock, more research needs to be conducted in order to review the parameters presently used to assess children for shock with a view of diagnosing and managing shock in these children when it is still early. Adequate guidance on use of IV fluids in management of severely malnourished children should be prioritized during continuous medical education for healthcare workers and in the treatment guidelines.
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Affiliation(s)
- Timothy Nduhukire
- Department of Pediatrics and Child Health, Kabale University, Kabale, Uganda
- * E-mail:
| | | | - Luwaga Rachel
- Department of Nursing, Bishop Stuart University, Mbarara, Uganda
| | - Joseph E. Byonanebye
- Department of Biomedical Sciences, Marquette University, Milwaukee, Winconsin, United States of America
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18
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Lysosome-Rich Enterocytes Mediate Protein Absorption in the Vertebrate Gut. Dev Cell 2019; 51:7-20.e6. [PMID: 31474562 PMCID: PMC6783362 DOI: 10.1016/j.devcel.2019.08.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/06/2019] [Accepted: 07/29/2019] [Indexed: 12/25/2022]
Abstract
The guts of neonatal mammals and stomachless fish have a limited capacity for luminal protein digestion, which allows oral acquisition of antibodies and antigens. However, how dietary protein is absorbed during critical developmental stages when the gut is still immature is unknown. Here, we show that specialized intestinal cells, which we call lysosome-rich enterocytes (LREs), internalize dietary protein via receptor-mediated and fluid-phase endocytosis for intracellular digestion and trans-cellular transport. In LREs, we identify a conserved endocytic machinery, composed of the scavenger receptor complex Cubilin/Amnionless and Dab2, that is required for protein uptake by LREs and for growth and survival of larval zebrafish. Moreover, impairing LRE function in suckling mice, via conditional deletion of Dab2, leads to stunted growth and severe protein malnutrition reminiscent of kwashiorkor, a devastating human malnutrition syndrome. These findings identify digestive functions and conserved molecular mechanisms in LREs that are crucial for vertebrate growth and survival.
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19
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Kulkarni B, Mamidi RS. Nutrition rehabilitation of children with severe acute malnutrition: Revisiting studies undertaken by the National Institute of Nutrition. Indian J Med Res 2019; 150:139-152. [PMID: 31670269 PMCID: PMC6829782 DOI: 10.4103/ijmr.ijmr_1905_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Indexed: 11/04/2022] Open
Abstract
Severe acute malnutrition (SAM) in children under five years is an important public health problem due to associated high mortality and long-term health consequences. Research on the dietary causes of SAM, especially the role and relative importance of dietary protein, in the aetiology of oedematous malnutrition, has led to considerable debates and controversies. The present article revisits some of the debates in this field, where the researchers at the National Institute of Nutrition (NIN), Hyderabad, India, with their pioneering work, have contributed to the global literature on the various facets of the disease. Highlighting the importance of energy as a bigger problem than protein malnutrition is a noteworthy contribution of NIN's research. It is, however, important to examine the protein quality of the diets in light of the new information on the lysine requirements. The article argues that the currently dominating hypothesis of free radical theory requires a critical review of the supporting evidence. Over the past few decades, the research has focused on low-cost diets using locally available foods. The article also argues that solutions based on local foods, being acceptable and sustainable, need to be strengthened for their effective delivery through the existing nutrition programmes. Recent evidence shows that the use of ready-to-use therapeutic foods (RUTF) with high micronutrient density may be linked with higher mortality possibly due to the high iron content, which could be counterproductive. There are several unaddressed concerns regarding the potential long-term impact of consumption of RUTF in children with SAM. More evidence and a cautious approach are, therefore, needed before implementing these solutions.
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Affiliation(s)
- Bharati Kulkarni
- Division of Maternal & Child Nutrition, ICMR-National Institute of Nutrition, Hyderabad, India
| | - Raja Sriswan Mamidi
- Division of Clinical Epidemiology, ICMR-National Institute of Nutrition, Hyderabad, India
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20
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Pham TPT, Tidjani Alou M, Bachar D, Levasseur A, Brah S, Alhousseini D, Sokhna C, Diallo A, Wieringa F, Million M, Raoult D. Gut Microbiota Alteration is Characterized by a Proteobacteria and Fusobacteria Bloom in Kwashiorkor and a Bacteroidetes Paucity in Marasmus. Sci Rep 2019; 9:9084. [PMID: 31235833 PMCID: PMC6591176 DOI: 10.1038/s41598-019-45611-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/14/2019] [Indexed: 12/22/2022] Open
Abstract
Kwashiorkor and marasmus are considered to be two different clinical diseases resulting from severe malnutrition, but this distinction has been questioned. In a previous study comparing children with kwashiorkor and healthy children from Niger and Senegal, we found a dramatic gut microbiota alteration with a predominant depletion of anaerobes and enrichment in Proteobacteria and Fusobacteria in kwashiorkor. However, it remained unknown whether this association was related to malnutrition or was a specific feature of kwashiorkor. In this continuation study, we added 7 new marasmus subjects and 71,162 new colonies from the same countries. Our results showed that, compared to marasmus, the kwashiorkor gut microbiota was characterized by an increased proportion of Proteobacteria (culturomics, Marasmus 5.0%, Kwashiorkor 16.7%, p < 0.0001; metagenomics, Marasmus 14.7%, Kwashiorkor 22.0%, p = 0.001), but there was a decreased proportion of Bacteroidetes in marasmus (culturomics, Marasmus 0.8%, Kwashiorkor 6.5%, p = 0.001; metagenomics, Marasmus 5.4%, Kwashiorkor 7.0%, p = 0.03). Fusobacterium was more frequently cultured from kwashiorkor. All detected potential pathogenic species were enriched in the kwashiorkor gut microbiota. These results provide a biological basis to support the usage of an antibiotic therapy more effective in suppressing the overgrowth of bacterial communities resistant to penicillin, combined with antioxidants and probiotics for nutritional recovery therapies, particularly for kwashiorkor.
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Affiliation(s)
- Thi-Phuong-Thao Pham
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - Maryam Tidjani Alou
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
- Institut de cancérologie Gustave Roussy Cancer Campus, Villejuif, France
| | - Dipankar Bachar
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - Anthony Levasseur
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - Souleymane Brah
- Service de Médecine Interne et Générale, Hôpital de Niamey, Niamey, Niger
| | - Daouda Alhousseini
- Service de Médecine Interne et Générale, Hôpital de Niamey, Niamey, Niger
| | - Cheikh Sokhna
- Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes IRD 198, Centre National de la Recherche Scientifique 7278, Aix-Marseille Université, Dakar, Senegal
| | - Aldiouma Diallo
- Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes IRD 198, Centre National de la Recherche Scientifique 7278, Aix-Marseille Université, Dakar, Senegal
| | - Frank Wieringa
- Institut de Recherche pour le Développement (IRD) - IRD/UM/SupAgro, Montpellier, France
| | - Matthieu Million
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France.
| | - Didier Raoult
- Aix-Marseille Univ, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Marseille, France.
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21
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Vitamin B 6 improves blood parameters in rats fed a protein-deficient diet and subjected to moderate, long-term exercise. Cent Eur J Immunol 2019; 44:23-32. [PMID: 31114433 PMCID: PMC6526596 DOI: 10.5114/ceji.2019.83266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/28/2019] [Indexed: 12/15/2022] Open
Abstract
Vitamin B6 is necessary for many enzymatic pathways (glucose and lipid metabolism, DNA/RNA synthesis, or modulation of gene expression) and affects immune cell function and blood-forming processes. We hypothesised that supplementing a protein-deficient diet with vitamin B6 may reduce the negative impact of protein malnutrition. Here, we evaluated the effect of moderate, long-term exercise (ninety days) on selected blood parameters in rats fed a normal diet, a protein-deficient diet, or a protein-deficient diet supplemented with vitamin B6. Selected haematological, immunological, and biochemical parameters were examined. A protein-deficient diet lasting 90 days caused significant reduction in body mass, increased activity of aminotransferases (asparagine and alanine), an increased percentage of innate cells in the blood, and decreased haemoglobin concentration in the blood. Adding vitamin B6 significantly increased body and muscle mass, decreased liver parameters, and caused normalisation of haemoglobin concentration and the proportion of white blood cells in the blood. These results indicate that vitamin B6 supplementation significantly improves the health of protein-malnourished rats and paves the way for the development of novel anti-malnutrition therapies.
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22
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Trehan I, Bassat Q. The Unbearable Lightness of Being Malnourished: Severe Acute Malnutrition Remains a Neglected Tropical Disease. J Trop Pediatr 2018; 64:169-173. [PMID: 29315432 DOI: 10.1093/tropej/fmx103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Indi Trehan
- Lao Friends Hospital for Children, Luang Prabang, Lao PDR.,Department of Pediatrics and Institute for Public Health, Washington University in St. Louis, St. Louis, MO 63110, USA
| | - Quique Bassat
- ISGlobal, Barcelona Centre for International Health Research, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.,ICREA, Barcelona 08010, Spain.,Pediatric Infectious Diseases Unit, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.,Universidad Europea de Madrid, Madrid, Spain
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23
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Abstract
The survival of a child with severe volume depletion at the emergency department depends on the competency of the first responder to recognize and promptly treat hypovolemic shock. Although the basic principles on fluid and electrolytes therapy have been investigated for decades, the topic remains a challenge, as consensus on clinical management protocol is difficult to reach, and more adverse events are reported from fluid administration than for any other drug. While the old principles proposed by Holliday and Segar, and Finberg have stood the test of time, recent systematic reviews and meta-analyses have highlighted the risk of hyponatraemia, and hyponatraemic encephalopathy in some children treated with hypotonic fluids. In the midst of conflicting literature on fluid and electrolytes therapy, it would appear that isotonic fluids are best suitable for the correction of hypotonic, isonatraemic, and hypernatraemic dehydration. Although oral rehydration therapy is adequate to correct mild to moderate isonatraemic dehydration, parenteral fluid therapy is safer for the child with severe dehydration and those with changes in serum sodium. The article reviews the pathophysiology of water and sodium metabolism and, it uses the clinical case examples to illustrate the bed-side approach to the management of three different types of dehydration using a pre-mixed isotonic fluid solution (with 20 or 40 mmol/L of potassium chloride added depending on the absence or presence of hypokalemia, respectively). When 3% sodium chloride is unavailable to treat hyponatraemic encephalopathy, 0.9% sodium chloride becomes inevitable, albeit, a closer monitoring of serum sodium is required. The importance of a keen and regular clinical and laboratory monitoring of a child being rehydrated is emphasized. The article would be valuable to clinicians in less-developed countries, who must use pre-mixed fluids, and who often cannot get some suitable rehydrating solutions.
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Affiliation(s)
- Emmanuel Ademola Anigilaje
- Nephrology Unit, Department of Paediatrics, College of Health Sciences, University of Abuja, Abuja, Nigeria
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24
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Downie ML, Gallibois C, Parekh RS, Noone DG. Nephrotic syndrome in infants and children: pathophysiology and management. Paediatr Int Child Health 2017; 37:248-258. [PMID: 28914167 DOI: 10.1080/20469047.2017.1374003] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Nephrotic syndrome is defined by nephrotic-range proteinuria (≥40 mg/m2/hour or urine protein/creatinine ratio ≥200 mg/mL or 3+ protein on urine dipstick), hypoalbuminaemia (<25 g/L) and oedema. This review focuses on the classification, epidemiology, pathophysiology, management strategies and prognosis of idiopathic nephrotic syndrome of childhood, and includes a brief overview of the congenital forms.
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Affiliation(s)
- Mallory L Downie
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada
| | - Claire Gallibois
- d Department of Medicine , Royal College of Surgeons in Ireland , Dublin , Ireland
| | - Rulan S Parekh
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada.,d Department of Medicine , Royal College of Surgeons in Ireland , Dublin , Ireland.,e Child Health Evaluative Sciences, Research Institute , The Hospital for Sick Children , Toronto , Canada.,f Division of Nephrology , University Health Network , Toronto , Canada.,g Dalla Lana School of Public Health , University of Toronto , Toronto , Canada
| | - Damien G Noone
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada
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25
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Abstract
The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.
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Affiliation(s)
- Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - James A Berkley
- Clinical Research Department, KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Robert H J Bandsma
- Centre for Global Child Health, Hospital for Sick Children, Peter Gilgan Centre for Research &Learning, 686 Bay Street, Toronto, Ontario, M5G 0A4, Canada
- The Childhood Acute Illness &Nutrition (CHAIN) Network, Nairobi, Kenya
- Department of Biomedical Sciences, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Marko Kerac
- Department of Population Health, London School of Hygiene &Tropical Medicine, London, UK
| | - Indi Trehan
- Lao Friends Hospital for Children, Luang Prabang, Laos
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
- Department of Paediatrics and Child Health, University of Malawi, Blantyre, Malawi
| | - André Briend
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
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Preidis GA, Kim KH, Moore DD. Nutrient-sensing nuclear receptors PPARα and FXR control liver energy balance. J Clin Invest 2017; 127:1193-1201. [PMID: 28287408 DOI: 10.1172/jci88893] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The nuclear receptors PPARα (encoded by NR1C1) and farnesoid X receptor (FXR, encoded by NR1H4) are activated in the liver in the fasted and fed state, respectively. PPARα activation induces fatty acid oxidation, while FXR controls bile acid homeostasis, but both nuclear receptors also regulate numerous other metabolic pathways relevant to liver energy balance. Here we review evidence that they function coordinately to control key nutrient pathways, including fatty acid oxidation and gluconeogenesis in the fasted state and lipogenesis and glycolysis in the fed state. We have also recently reported that these receptors have mutually antagonistic impacts on autophagy, which is induced by PPARα but suppressed by FXR. Secretion of multiple blood proteins is a major drain on liver energy and nutrient resources, and we present preliminary evidence that the liver secretome may be directly suppressed by PPARα, but induced by FXR. Finally, previous studies demonstrated a striking deficiency in bile acid levels in malnourished mice that is consistent with results in malnourished children. We present evidence that hepatic targets of PPARα and FXR are dysregulated in chronic undernutrition. We conclude that PPARα and FXR function coordinately to integrate liver energy balance.
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27
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Kuwahata M, Hasegawa M, Kobayashi Y, Wada Y, Kido Y. An oxidized/reduced state of plasma albumin reflects malnutrition due to an insufficient diet in rats. J Clin Biochem Nutr 2017; 60:70-75. [PMID: 28163385 PMCID: PMC5281528 DOI: 10.3164/jcbn.16-33] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/29/2016] [Indexed: 02/06/2023] Open
Abstract
We examined whether protein- and food-intake restrictions modulate the oxidized/reduced state of plasma albumin in Sprague-Dawley rats. Rats were fed a 3%, 5%, 10% or 20% casein diet for 2 weeks. The plasma albumin concentration significantly decreased with decreasing protein intake. However, no significant difference in plasma albumin concentration was seen between rats fed the 5% or 10% casein diet. In rats fed the 5% casein diet, the percentage of mercaptalbumin within total plasma albumin was significantly lower and that of nonmercaptalbumin-1 was significantly higher than in rats fed the 10% casein diet. In experiments with food-intake restriction for 2 weeks, rats were fed 50% or 75% of the amount of a 20% casein diet consumed by control rats. The percentage of mercaptalbumin was significantly lower and that of nonmercaptalbumin-2 was significantly higher in rats with food-intake restriction than in control rats. When rats with malnutrition were refed with the 20% casein diet ad libitum, the percentage of mercaptalbumin rapidly increased. The change in the percentage of mercaptalbumin was correlated with the plasma transthyretin concentration. These results indicate that the oxidized/reduced state of plasma albumin may be applied as a sensitive marker of nutritional status reflecting dietary pattern.
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Affiliation(s)
- Masashi Kuwahata
- Departments of Nutrition Science, Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, 1-5 Shimogamo-hangi-cho, Sakyo, Kyoto 606-8522, Japan
| | - Mari Hasegawa
- Departments of Nutrition Science, Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, 1-5 Shimogamo-hangi-cho, Sakyo, Kyoto 606-8522, Japan
| | - Yukiko Kobayashi
- Departments of Nutrition Science, Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, 1-5 Shimogamo-hangi-cho, Sakyo, Kyoto 606-8522, Japan
| | - Yasuaki Wada
- Nutritional Science Institute, Morinaga Milk Industry Co., Ltd., 5-1-83 Higashihara, Zama, Kanagawa 252-8583, Japan
| | - Yasuhiro Kido
- Departments of Nutrition Science, Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, 1-5 Shimogamo-hangi-cho, Sakyo, Kyoto 606-8522, Japan
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