Constitutive, but not challenge-induced, interleukin-10 production is robust in acute pre-pubescent protein and energy deficits: new support for the tolerance hypothesis of malnutrition-associated immune depression based on cytokine production in vivo

Association between Controlling Nutritional Status (CONUT) Score and Body Composition, Inflammation and Frailty in Hospitalized Elderly Patients

The Controlling Nutritional Status (CONUT) score has demonstrated its ability to identify patients with poor nutritional status and predict various clinical outcomes. Our objective was to assess the association between the CONUT score, inflammatory status, and body composition, as well as its ability to identify patients at risk of frailty in hospitalized elderly patients.

METHODS

a total of 361 patients were retrospectively recruited and divided into three groups based on the CONUT score.

RESULTS

patients with a score ≥5 exhibited significantly higher levels of inflammatory markers, such as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Neutrophil/Lymphocytes ratio (NLR), main platelet volume (MPV), and ferritin, compared to those with a lower score. Furthermore, these patients showed unfavorable changes in body composition, including a lower percentage of skeletal muscle mass (MM) and fat-free mass (FFM) and a higher percentage of fatty mass (FM). A positive correlation was found between the CONUT score and inflammatory markers, Geriatric Depression Scale Short Form (GDS-SF), and FM. Conversely, the Mini Nutritional Assessment (MNA), Mini-Mental Status Examination, activity daily living (ADL), instrumental activity daily living (IADL), Barthel index, FFM, and MM showed a negative correlation. Frailty was highly prevalent among patients with a higher CONUT score. The receiver operating characteristic (ROC) curve demonstrated high accuracy in identifying frail patients (sensitivity).

CONCLUSIONS

a high CONUT score is associated with a pro-inflammatory status as well as with unfavorable body composition. Additionally, it is a good tool to identify frailty among hospitalized elderly patients.

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.

Vaccine and malnutrition: A narrative review

Nearly 45% of under 5 mortality is directly or indirectly linked to malnutrition. Infection adds to the increased mortality and morbidity in these groups. Vaccination is very important in these undernourished children protecting against life-threatening infections. The goal of vaccination is to produce long-term protection by generating memory cells and the generation of antibodies. Since malnutrition is a state of immunodeficiency, the immune response to vaccines in these children is a matter of concern. We did an exhaustive search to gather more recent studies and corroborated previous findings. Oral Polio Vaccine (OPV), Pneumococcal Polysaccharide Vaccine, Haemophilus influenza vaccine, rabies, and cholera vaccine showed normal response to immunization. Measles and rotavirus vaccines were found to elicit lower seroprotection and lower efficacy in undernourished children. Data regarding response to vaccination against BCG, DPwT, Hepatitis B, pneumococcal conjugate vaccine, and meningococcal vaccine was inconclusive. Although most of the studies show a normal immune response to different vaccines, excluding other confounding factors and effect modifiers had not been easy to interpret. However, with the advances in the understanding of vaccine physiology with newer immunological techniques, good-quality studies might explore the gray areas that remain untouched.

Correlation of Cytokines with Parasitic Infections, Undernutrition and Micronutrient Deficiency among Schoolchildren in Rural Tanzania: A Cross-Sectional Study

Malnutrition and parasitic infections are often interconnected in a vicious cycle. Malnutrition can lead to changes in immune response, which may affect cytokine concentrations and potentially increase susceptibility to infections. In turn, parasitic infections can exacerbate malnutrition by impairing nutrient absorption. This cross-sectional study aimed to explore this interplay. Schoolchildren aged 6-12 years living in rural Tanzania (n = 120) provided blood, stool and urine samples to determine the relationship between cytokine concentrations (interleukin 4 (IL-4), interferon gamma (IFNγ) and interleukin 17A (IL-17A)), parasitic infections, undernutrition and micronutrient deficiency adjusting for sex, age, inflammatory markers, socioeconomic status and school categories. All schoolchildren had a normal blood cell count. The concentration of IL-4 was significantly higher in schoolchildren diagnosed with stunting, Schistosoma mansoni infection, a high C-reactive protein concentration, nausea, poor housing and increasing age. The concentration of IFNγ was associated with Plasmodium falciparum and Entamoeba histolytica/Entamoeba dispar/Entamoeba moshkovskii infections, vitamin A deficiency, attending the most remote schools and low socioeconomic status. Our study confirms a potential relationship between cytokine concentrations and parasitic infections, malnutrition and low socioeconomic status. A better understanding of long-term effects of parasitic infections and malnutrition on the immune function could help in designing tailored and effective interventions.

Perspectives on urea cycle disorder management: Results of a clinician survey

BACKGROUND/AIMS

Urea cycle disorders (UCDs) are rare inborn errors of urea synthesis. US and European consensus statements on the diagnosis and treatment of UCDs were last published in 2001 and 2019, respectively. Recommendations are based primarily on case reports and expert opinion and there is limited agreement or consistency related to long-term management approaches. A clinician survey was conducted to assess current real-world practices and perspectives on challenges and unmet needs.

METHODS

A 14-item multiple-choice survey was administered to physicians in 2017. Clinicians who reported actively managing at least 1 patient with UCD were eligible to participate. Descriptive statistics were calculated for each survey item (frequencies for categorical variables; means, standard deviations, medians, and ranges for continuous variables).

RESULTS

Sixty-six US clinicians completed the survey (65 geneticists; 1 pediatric neurologist). Over 90% of responders agreed or strongly agreed that even modest elevations in ammonia could cause physiological and functional brain damage; >80% of respondents agreed that asymptomatic UCD patients are at risk of brain damage over time due to mild/subclinical elevations in ammonia. Eighty-six percent of clinicians agreed or strongly agreed with recommending genetic testing for female relatives when a patient is diagnosed with ornithine transcarbamylase deficiency. Ninety-four percent of respondents agreed that patients have better disease control when they are more adherent to their UCD therapy. Nearly 90% indicated that clinicians and patients would benefit from updated UCD management guidance. More than half (53%) of respondents rated the symptoms of UCDs as extremely or very burdensome to the everyday lives of patients and their families; only 8% rated UCD symptoms as slightly or not at all burdensome. The majority of clinicians agreed (48%) or strongly agreed (32%) that caring for a child or family member with a UCD has a negative impact on the quality of life and/or health of family members/guardians (e.g. stress, relationships, ability to work).

CONCLUSIONS

This self-reported survey suggests a need for updated and expanded clinical guidance on the long-term treatment and management of UCD patients.

Acutely malnourished weanling mice administered Flt3 ligand can support a cell-mediated inflammatory response

The main objective of this investigation was to determine whether, despite acute (wasting) deficits of dietary nitrogen and energy, weanling mice could respond to the dendritic cell hematopoietin, Fms-like tyrosine kinase 3 ligand (Flt3L), in terms of an index of cell-mediated inflammatory competence. Male and female C57BL/6J weanlings were used, initially 19 days of age, and malnutrition was produced using a nitrogen-deficient diet. In preliminary work ten daily subcutaneous 1.0 µg doses of murine Flt3L, comparable to a protocol effective in humans, expanded the splenic conventional dendritic cell compartment (CD11c⁺F4/80^-/low) of healthy weanlings without affecting the numbers of lymphocytes, macrophages, or recoverable mononuclear cells. Two subsequent experiments showed that, despite advancing malnutrition, exogenous Flt3L was able both to exert its classic influence on splenic conventional dendritic cell numbers and to invigorate the attenuated primary splenic cell-mediated inflammatory response to sheep erythrocytes. A final experiment showed that the cytokine intervention did not affect dendritic cell maturity according to several phenotypic indices. The findings provide new support for the proposition that dendritic cell numbers are the first limiting factor in the weak cell-mediated immune competence of acute pre-pubescent malnutrition. More substantially, intervention with Flt3L sustained an inflammatory systemic immune character despite progressive weanling malnutrition and weight loss. This outcome provides new support of fundamental character for the Tolerance Model which posits that the cell-mediated inflammatory incompetence of acute pre-pubescent protein and energy deficits is a regulated adaptive attempt, the antithesis of the classic paradigm of unregulated immunological attrition.

IL-6, TNF-α, IL-10, and nutritional status in pediatric patients with biliary atresia

OBJECTIVES

The objective of the present study is to evaluate whether IL-6, TNF-α, IL-10 are associated with nutritional status in patients with cirrhosis secondary to biliary atresia and compare to healthy controls.

METHODS

The parameters used for nutritional assessment were the standard deviation scores of height-for-age and of triceps skinfold thickness-for-age. The severity of cirrhosis was evaluated using the Child-Pugh score and PELD/MELD. Serum cytokines were measured using Cytometric Bead Array flow cytometry.

RESULTS

IL-6, TNF-α, and IL-10 were significantly higher in the cirrhosis group when compared with the control group (2.4 vs. 0.24 (p<0.001), 0.21 vs. 0.14 (p=0.007), and 0.65 vs. 0.36 (p=0.004), respectively. IL-6 and IL-10 were positively correlated with disease severity (0.450 [p=0.001] and 0.410; [p=0.002], respectively). TNF-α did not show a significant correlation with disease severity (0.100; p=0.478). Regarding nutritional evaluation, IL-6 was negatively correlated with the standard deviation score of height-for-age (-0.493; p<0.001) and of triceps skinfold thickness-for-age (-0.503; p<0.001), respectively. IL-10 exhibited a negative correlation with the standard deviation score of height-for-age (-0.476; p<0.001) and the standard deviation score of triceps skinfold thickness-for-age (-0.388; p=0.004). TNF-α did not show any significance in both anthropometric parameters (-0.083 (p=0.555) and -0.161 (p=0.253).

CONCLUSION

The authors suggest that, in patients with cirrhosis secondary to biliary atresia, IL-6 could be used as a possible supporting biomarker of deficient nutritional status and elevated IL-10 levels could be used as a possible early-stage supporting biomarker of deteriorating nutritional status.

Fidelity in Animal Modeling: Prerequisite for a Mechanistic Research Front Relevant to the Inflammatory Incompetence of Acute Pediatric Malnutrition

Inflammatory incompetence is characteristic of acute pediatric protein-energy malnutrition, but its underlying mechanisms remain obscure. Perhaps substantially because the research front lacks the driving force of a scholarly unifying hypothesis, it is adrift and research activity is declining. A body of animal-based research points to a unifying paradigm, the Tolerance Model, with some potential to offer coherence and a mechanistic impetus to the field. However, reasonable skepticism prevails regarding the relevance of animal models of acute pediatric malnutrition; consequently, the fundamental contributions of the animal-based component of this research front are largely overlooked. Design-related modifications to improve the relevance of animal modeling in this research front include, most notably, prioritizing essential features of pediatric malnutrition pathology rather than dietary minutiae specific to infants and children, selecting windows of experimental animal development that correspond to targeted stages of pediatric immunological ontogeny, and controlling for ontogeny-related confounders. In addition, important opportunities are presented by newer tools including the immunologically humanized mouse and outbred stocks exhibiting a magnitude of genetic heterogeneity comparable to that of human populations. Sound animal modeling is within our grasp to stimulate and support a mechanistic research front relevant to the immunological problems that accompany acute pediatric malnutrition.

Protein malnutrition alters spleen cell proliferation and IL-2 and IL-10 production by affecting the STAT-1 and STAT-3 balance

Protein malnutrition (PM) is an important public health problem that affects resistance to infection by impairing a number of physiological processes. PM induces structural changes in the lymphoid organs that affect the roles of the immune and inflammatory responses in a crucial way. The activation of different transcription factors, including signal transducer and activator of transcription (STAT) family members, leads to the production of different cytokines, which are mediators essential to mounting adequate immune and inflammatory responses. In this study, malnourished animals presented anemia, leukopenia, and a severe reduction in spleen cellularity, with reduced numbers of most cell populations, as well as increased percentages of CD3(+) and CD4(+) cells. The proliferation rates were reduced, and cells were increasingly observed in the G0/G1 cell cycle phase; further, IL-2 production was reduced, while IL-10 production was increased. In spleen cells from malnourished animals, STAT-3 protein expression was increased, with a concomitant reduction in STAT-1 expression. Knowing that STAT-1 and STAT-3 are key transcription factors in both immunity and inflammatory pathways, these results infer, at least in part, a mechanistic pathway that affects the manner or intensity of the immune response in malnourished individuals, increasing susceptibility to infection.

The immune system in children with malnutrition--a systematic review

BACKGROUND

Malnourished children have increased risk of dying, with most deaths caused by infectious diseases. One mechanism behind this may be impaired immune function. However, this immune deficiency of malnutrition has not previously been systematically reviewed.

OBJECTIVES

To review the scientific literature about immune function in children with malnutrition.

METHODS

A systematic literature search was done in PubMed, and additional articles identified in reference lists and by correspondence with experts in the field. The inclusion criteria were studies investigating immune parameters in children aged 1-60 months, in relation to malnutrition, defined as wasting, underweight, stunting, or oedematous malnutrition.

RESULTS

The literature search yielded 3402 articles, of which 245 met the inclusion criteria. Most were published between 1970 and 1990, and only 33 after 2003. Malnutrition is associated with impaired gut-barrier function, reduced exocrine secretion of protective substances, and low levels of plasma complement. Lymphatic tissue, particularly the thymus, undergoes atrophy, and delayed-type hypersensitivity responses are reduced. Levels of antibodies produced after vaccination are reduced in severely malnourished children, but intact in moderate malnutrition. Cytokine patterns are skewed towards a Th2-response. Other immune parameters seem intact or elevated: leukocyte and lymphocyte counts are unaffected, and levels of immunoglobulins, particularly immunoglobulin A, are high. The acute phase response appears intact, and sometimes present in the absence of clinical infection. Limitations to the studies include their observational and often cross-sectional design and frequent confounding by infections in the children studied.

CONCLUSION

The immunological alterations associated with malnutrition in children may contribute to increased mortality. However, the underlying mechanisms are still inadequately understood, as well as why different types of malnutrition are associated with different immunological alterations. Better designed prospective studies are needed, based on current understanding of immunology and with state-of-the-art methods.

Association of IL-6, IL-10, and TNF-α gene polymorphism with malnutrition inflammation syndrome and survival among end stage renal disease patients

During end stage renal disease (ESRD) inflammatory pathways are activated which may lead to malnutrition inflammation syndrome (MIS). In the present study, 257 ESRD patients and 200 controls were included. Cytokine levels and genotyping was done by polymerase chain reaction-restriction fragment length polymorphism and enzyme-linked immunosorbent assay (ELISA). Risk was estimated through binary logistic regression. Cox proportional hazards regression and Kaplan-Meier were used for survival analysis. Tumor necrosis factor TNF-α-308 AA conferred 3.6-fold higher susceptibility (P=0.001) and higher TNF-α levels (P=0.05). TNF-α-238 AA was associated with 3.3-fold higher susceptibility to ESRD (P=0.002). IL-6-174 CC genotype conferred 3-fold risk to disease (P=0.001) along with higher IL-6 levels (P=0.001). IL-10-1082 GG genotype exhibited 2.2-fold higher susceptibility to disease (P=0.013). IL-10-592 AA/-819 TT genotypes were associated with high C reactive protein (P=0.02) and low IL-10 (P=0.03) levels. TNF-α-308 A allele was significantly associated with 2.3-fold higher risk of malnutrition. TNF-α-GAC, AGC and IL-6-CC were risk haplotypes associated with higher disease susceptibility. Combined analysis revealed 1.6-fold higher susceptibility to disease (P=0.02), there was 2-fold higher susceptibility to malnutrition (P=0.02) in high inflammation group. TNF-α-238 AA genotype was associated with 2.5-fold higher death hazard risk (P=0.02). Our study suggests that TNF-α and its genetic variants are major contributors to susceptibility to MIS in ESRD patients.