Protein energy malnutrition pathophysiology: Difference between revisions
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==Overview== | ==Overview== | ||
Several acute malnutrition affects many organs of the body. Several theories have been put forward to explain the various forms in which the organs are affected. Some of the major organ systems affected include cardiovascular system,<ref name="pmid26553908">{{cite journal| author=Silverman JA, Chimalizeni Y, Hawes SE, Wolf ER, Batra M, Khofi H et al.| title=The effects of malnutrition on cardiac function in African children. | journal=Arch Dis Child | year= 2016 | volume= 101 | issue= 2 | pages= 166-71 | pmid=26553908 | doi=10.1136/archdischild-2015-309188 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26553908 }} </ref> liver,<ref name="pmid1471885">{{cite journal| author=Doherty JF, Adam EJ, Griffin GE, Golden MH| title=Ultrasonographic assessment of the extent of hepatic steatosis in severe malnutrition. | journal=Arch Dis Child | year= 1992 | volume= 67 | issue= 11 | pages= 1348-52 | pmid=1471885 | doi= | pmc=1793750 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1471885 }} </ref> genitourinary system,<ref name="pmid12700964">{{cite journal| author=Bagga A, Tripathi P, Jatana V, Hari P, Kapil A, Srivastava RN et al.| title=Bacteriuria and urinary tract infections in malnourished children. | journal=Pediatr Nephrol | year= 2003 | volume= 18 | issue= 4 | pages= 366-70 | pmid=12700964 | doi=10.1007/s00467-003-1118-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12700964 }} </ref> gastrointestinal tract, immune system,<ref name="pmid9129488">{{cite journal| author=Sauerwein RW, Mulder JA, Mulder L, Lowe B, Peshu N, Demacker PN et al.| title=Inflammatory mediators in children with protein-energy malnutrition. | journal=Am J Clin Nutr | year= 1997 | volume= 65 | issue= 5 | pages= 1534-9 | pmid=9129488 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9129488 }} </ref> endocrine system, metabolism and circulation,<ref name="pmid22386944">{{cite journal| author=Spoelstra MN, Mari A, Mendel M, Senga E, van Rheenen P, van Dijk TH et al.| title=Kwashiorkor and marasmus are both associated with impaired glucose clearance related to pancreatic β-cell dysfunction. | journal=Metabolism | year= 2012 | volume= 61 | issue= 9 | pages= 1224-30 | pmid=22386944 | doi=10.1016/j.metabol.2012.01.019 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22386944 }} </ref> cellular function skin and glands. | |||
==Pathophysiology== | ==Pathophysiology== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Omodamola Aje B.Sc, M.D. [2]
Overview
Several acute malnutrition affects many organs of the body. Several theories have been put forward to explain the various forms in which the organs are affected. Some of the major organ systems affected include cardiovascular system,[1] liver,[2] genitourinary system,[3] gastrointestinal tract, immune system,[4] endocrine system, metabolism and circulation,[5] cellular function skin and glands.
Pathophysiology
Pathogenesis
There are 3 major theories that have been proposed to describe the mechanism of edema in the kwashiorkor patient.
1. Protein deficiency/hypoalbuminemia : It was initially believed that a deficiency in the consumption of protein was responsible for the development of kwashiorkor in children.
- Albumin concentrations were also noted to increase steadily within two weeks after refeeding.
- Presence of features similar to congenital nephrotic syndrome, in which the primary pathology is renal loss of albumin.[6]
Multiple evidences have now shown that inadequate intake of dietary protein is not the primary trigger for edematous malnutrition.
- Some patients have edematous malnutrition without hypoalbuminemia
- Others develop edematous malnutrition (kwashiorkor) despite adequate proportion of protein in the diet (eg, in exclusively breastfed infants)
- Others recover from edematous malnutrition with supportive care even without enhancing the protein content of the diet.[7][8][9]
2. Oxidant stress : Excessive oxidant stress was also proposed as a mechanism of development of kwashorkor, however, it was discovered that that the administration of antioxidant was not successful in prevention of the development of this malnutrition in a series of trials. Hence the conclusion that antioxidant depletion is a consequence rather than cause of kwashiorkor.[10]
3. Microbiome : Changes in intestinal microbiome has also been suggested as a cause of the development of kwashiorkor. However, these has not been fully supported because evidences show that neither the fecal microbiota transfer nor the local diet alone was sufficient to cause the malnutrition leading to the conclusion that changes in fecal microbiota are only effects rather than causes of kwashiorkor.[11][12][13]
Genetics
Associated conditions
Some of the conditions that are associated with kwashiokor include;
- Vitamin A deficiency
- Vitamin D deficiency
- Thiamine deficiency
- Zinc deficiency
- Dehydration
- Sepsis
- Shigella and Campylobacter infections.
Gross pathology
Post mortem examination of the liver shows the presence of fatty infiltration and necrosis which disappears with adequate treatment.
Microscopic pathology
References
- ↑ Silverman JA, Chimalizeni Y, Hawes SE, Wolf ER, Batra M, Khofi H; et al. (2016). "The effects of malnutrition on cardiac function in African children". Arch Dis Child. 101 (2): 166–71. doi:10.1136/archdischild-2015-309188. PMID 26553908.
- ↑ Doherty JF, Adam EJ, Griffin GE, Golden MH (1992). "Ultrasonographic assessment of the extent of hepatic steatosis in severe malnutrition". Arch Dis Child. 67 (11): 1348–52. PMC 1793750. PMID 1471885.
- ↑ Bagga A, Tripathi P, Jatana V, Hari P, Kapil A, Srivastava RN; et al. (2003). "Bacteriuria and urinary tract infections in malnourished children". Pediatr Nephrol. 18 (4): 366–70. doi:10.1007/s00467-003-1118-0. PMID 12700964.
- ↑ Sauerwein RW, Mulder JA, Mulder L, Lowe B, Peshu N, Demacker PN; et al. (1997). "Inflammatory mediators in children with protein-energy malnutrition". Am J Clin Nutr. 65 (5): 1534–9. PMID 9129488.
- ↑ Spoelstra MN, Mari A, Mendel M, Senga E, van Rheenen P, van Dijk TH; et al. (2012). "Kwashiorkor and marasmus are both associated with impaired glucose clearance related to pancreatic β-cell dysfunction". Metabolism. 61 (9): 1224–30. doi:10.1016/j.metabol.2012.01.019. PMID 22386944.
- ↑ Coulthard MG (2015). "Oedema in kwashiorkor is caused by hypoalbuminaemia". Paediatr Int Child Health. 35 (2): 83–9. doi:10.1179/2046905514Y.0000000154. PMC 4462841. PMID 25223408.
- ↑ Golden MH (1998). "Oedematous malnutrition". Br Med Bull. 54 (2): 433–44. PMID 9830208.
- ↑ Manary MJ, Heikens GT, Golden M (2009). "Kwashiorkor: more hypothesis testing is needed to understand the aetiology of oedema". Malawi Med J. 21 (3): 106–7. PMC 3717490. PMID 20345018.
- ↑ Golden MH (2015). "Nutritional and other types of oedema, albumin, complex carbohydrates and the interstitium - a response to Malcolm Coulthard's hypothesis: Oedema in kwashiorkor is caused by hypo-albuminaemia". Paediatr Int Child Health. 35 (2): 90–109. doi:10.1179/2046905515Y.0000000010. PMID 25844980.
- ↑ Ciliberto H, Ciliberto M, Briend A, Ashorn P, Bier D, Manary M (2005). "Antioxidant supplementation for the prevention of kwashiorkor in Malawian children: randomised, double blind, placebo controlled trial". BMJ. 330 (7500): 1109. doi:10.1136/bmj.38427.404259.8F. PMC 557886. PMID 15851401.
- ↑ Smith MI, Yatsunenko T, Manary MJ, Trehan I, Mkakosya R, Cheng J; et al. (2013). "Gut microbiomes of Malawian twin pairs discordant for kwashiorkor". Science. 339 (6119): 548–54. doi:10.1126/science.1229000. PMC 3667500. PMID 23363771.
- ↑ Prentice AM, Nabwera H, Kwambana B, Antonio M, Moore SE (2013). "Microbes and the malnourished child". Sci Transl Med. 5 (180): 180fs11. doi:10.1126/scitranslmed.3006212. PMID 23576812.
- ↑ Kau AL, Planer JD, Liu J, Rao S, Yatsunenko T, Trehan I; et al. (2015). "Functional characterization of IgA-targeted bacterial taxa from undernourished Malawian children that produce diet-dependent enteropathy". Sci Transl Med. 7 (276): 276ra24. doi:10.1126/scitranslmed.aaa4877. PMC 4423598. PMID 25717097.