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Kwashiorkor--is it a dying disease?S
Afr Med J. 2007 Jan;97(1):65-8.
OBJECTIVE: To
review the occurrence of kwashiorkor before and after the
establishment of the Diarrhoea Training Unit at a Nigerian tertiary
hospital in 1992. DESIGN: A retrospective hospital-based analytical
study was undertaken. Groups of subjects were compared using odds
ratios (95% confidence intervals) and regression analysis. SETTING:
The paediatric wards of the Wesley Guild Hospital, Ilesa, Nigeria.
SUBJECTS: The number of children admitted with kwashiorkor, measles,
gastroenteritis and marasmus between 1983 and 1991 (group I) was
compared with similar data for the period 1993-2002 (group 2).
RESULTS: There was a 30.4% reduction in the total admissions between
these periods, while incidences of kwashiorkor, measles,
gastroenteritis and marasmus fell by 70%, 55%, 57.4% and 55.8%
respectively. Reduction in number of kwashiorkor cases between groups
1 and 2 was significantly related to the reduced incidence of measles
(p = 0.000002) and gastroenteritis (p = 0.000003). The total number of
admissions was correlated with the number of measles (r = 0.623 and
0.573 for group 1 and 2) and kwashiorkor cases (r = -0.412 and 0.233
for groups 1 and 2). CONCLUSION: The incidence of kwashiorkor has
fallen in Ilesa, Nigeria. Given the relatively low HIV prevalence rate
in the country during the study period, better management of
diarrhoeal diseases, including measles, may have accounted for this
drastic fall.
The clinical manifestation of the kwashiorkor syndrome is related to
increased lipid peroxidation.J
Pediatr. 1998 May;132(5):879-81.
Along with the
onset of severe kwashiorkor symptoms, a 20-month-old child showed
biochemical signs of markedly increased lipid peroxidation, with a
decrease of plasma antioxidants and decreased proportions of
polyunsaturated fatty acids in plasma and red cell phospholipids.
Additionally, plasma concentrations of the lipid peroxidation products
malondialdehyde and hexanal, as well as the urinary excretion of
leukotriene E4, were found to be increased. All biochemical
alterations normalized along with subsequent clinical improvement.
These findings suggest that the extent of lipid peroxidation is
strongly related to the severity of the kwashiorkor syndrome.
Intestinal
permeability in kwashiorkor.Arch
Dis Child. 1997 Mar;76(3):236-41.
Intestinal
permeability can be assessed non-invasively using the
lactulose-rhamnose (L-R) test, which is a reliable measure of small
intestinal integrity. AIMS: To determine risk factors for abnormal
intestinal permeability in kwashiorkor, and to measure changes in L-R
ratios with inpatient rehabilitation. DESIGN: A case-control study of
149 kwashiorkor cases and 45 hospital controls. The L-R test was
adapted to study kwashiorkor in Malawi, with testing at weekly
intervals during nutritional rehabilitation. Urine sugars were
measured by thin layer chromatography in London. RESULTS: The initial
geometric mean L-R ratios (x100) (with 95% confidence interval) in
kwashiorkor were 17.3 (15.0 to 19.8) compared with 7.0 (5.6 to 8.7)
for controls. Normal ratios are < 5, so the high ratios in controls
indicate tropical enteropathy syndrome. Abnormal permeability in
kwashiorkor was associated with death, oliguria, sepsis, diarrhoea,
wasting and young age. Diarrhoea and death were associated with both
decreased L-rhamnose absorption (diminished absorptive surface area)
and increased lactulose permeation (impaired barrier function) whereas
nutritional wasting affected only L-rhamnose absorption. Despite,
clinical recovery, mean L-R ratios improved little on treatment, with
mean weekly ratios of 16.3 (14.0 to 19.0), 13.3 (11.1 to 15.9) and
14.4 (11.0 to 18.8). CONCLUSION: Abnormal intestinal permeability in
kwashiorkor correlates with disease severity, and improves only slowly
with nutritional rehabilitation.
Whole-body protein
kinetics in marasmus and kwashiorkor during acute infection.Am
J Clin Nutr. 1998 Jun;67(6):1205-9.
Marasmus and
kwashiorkor are clinically distinct manifestations of severe
malnutrition. This study tested the hypothesis that rates of
whole-body protein synthesis and breakdown are higher in marasmus than
in kwashiorkor during acute infection. We measured whole-body protein
kinetics using stable isotope tracers in eight children with marasmus
and acute infection (pneumonia or malaria) to determine the rate of
appearance of urea and leucine in plasma. Serum concentrations of
total protein, albumin, and C-reactive protein were also measured.
These findings were compared with those reported previously for 13
children with kwashiorkor (including marasmic kwashiorkor) and acute
infection who were studied with the same methods. HIV infection was
present in 10 of 21 children. Rates of protein breakdown and synthesis
were higher in marasmus than in kwashiorkor (227 +/- 59 compared with
103 +/- 30 micromol leucine x kg(-1) x h(-1) and 216 +/- 60 compared
with 97 +/- 30 micromol leucine x kg(-1) x h(-1), P < 0.001). The
concentration of globulin (total protein minus albumin) was higher in
marasmus than kwashiorkor (40 +/- 17 compared with 25 +/- 7 g/L, P <
or = 0.01), but C-reactive protein was not different (73 +/- 79
compared with 83 +/- 89 mg/L). HIV infection and body composition did
not explain the differences between marasmus and kwashiorkor. The
accelerated rate of protein turnover in children with marasmus and
acute infection requires further investigation.
Severe
hypophosphatemia in children with kwashiorkor is associated with
increased mortality.J
Pediatr. 1998 Dec;133(6):789-91.
Severe
hypophosphatemia, serum phosphate concentration <0.32 mmol/L (<1.0 mg/dL),
occurred in 8 of 68 (12%) of children with kwashiorkor within 48 hours
of admission; 5 of 8 (63%) of these children died, compared with 13 of
60 (22%) children without severe hypophosphatemia (P <.02). Dermatosis
and dehydration were significantly correlated with severe
hypophosphatemia, but these clinical signs could not reliably predict
fatal cases. Severe hypophosphatemia seems to be common and
life-threatening in children with kwashiorkor in Malawi.
PIP: Severe hypophosphatemia, serum inorganic phosphate concentration
of less than 0.32 mmol/l, is associated with leukocyte dysfunction,
acute respiratory decompensation, cardiac arrhythmias, and heart
failure. The condition has been described in children with kwashiorkor
from South Africa, but not in children from Jamaica or India. In acute
kwashiorkor in sub-Saharan Africa, the case fatality rate remains
high, often over 20%, despite the implementation of standard treatment
protocols. The authors examined whether severe hypophosphatemia was
frequent at presentation or during initial refeeding among Malawian
children with kwashiorkor and whether it was associated with a fatal
outcome. All children under age 10 years who presented with
kwashiorkor to the Queen Elizabeth Central Hospital in Blantyre during
a 2-month period were eligible and enrolled in the study. 68 children
with kwashiorkor were studied. Severe hypophosphatemia occurred in 8
(12%) children with kwashiorkor within 48 hours of admission. 5 of
these 8 (63%) children died, compared with 13 of 60 (22%) children
without severe hypophosphatemia. Dermatosis and dehydration were
significantly correlated with severe hypophosphatemia, but these
clinical signs could not reliably predict fatal cases. Severe
hypophosphatemia appears to be common and life-threatening in children
with kwashiorkor in Malawi.
Effect of
kwashiorkor on the cardiovascular system.Arch
Dis Child. 1988;63(11):1359-62.
In kwashiorkor
the heart is clinically and radiologically small. This study utilises
echocardiography, a tool not previously used in this disease, to show
that this is due to decreased muscle mass.
The influence
of aflatoxins on child health in the tropics with particular reference
to kwashiorkor.Trans
R Soc Trop Med Hyg. 1984;78(4):427-35.
Aflatoxins are
common environmental hazards in all the underdeveloped countries of
the tropics where they commonly contaminate food. They are toxic to
most species of animals and are among the most powerful carcinogenic
agents known. The liver is the principal target for toxicity.
Metabolic derangements caused by aflatoxins include depression of
protein and enzyme synthesis, disorder of lipid metabolism and
immunological suppression. The aetiology and pathogenesis of
kwashiorkor remains somewhat obscure. Similarities in the geographical
and climatic prevalence of kwashiorkor and aflatoxins and similarities
in the metabolic derangements caused by aflatoxins and those observed
in kwashiorkor, prompted investigation of the relationship between
aflatoxin and kwashiorkor in the Sudan and elsewhere in Africa.
Analysis of foods from markets and in homes revealed widespread
aflatoxin contamination. Aflatoxins were found more frequently and at
higher concentrations in the serum of children with kwashiorkor than
in those with other types of malnutrition or in normal children.
Aflatoxicol, a metabolite of aflatoxin B1 was detected in serum in
kwashiorkor and marasmic kwashiorkor but not in normally nourished
children and only once in marasmus. Autopsy liver samples from West
and Southern Africa have shown aflatoxins in all cases of kwashiorkor
but not in marasmus. These findings establish relationships between
aflatoxin and kwashiorkor the nature of which remains obscure but
includes the possibility of a causal association.
Aflatoxins and
kwashiorkor: a study in Sudanese children.Br Med J (Clin Res Ed). 1982
September 25; 285(6345): 843–846.
Blood and
urine samples from 252 Sudanese children were investigated for their
aflatoxin content by high-performance liquid chromatography. The
children comprised 44 with kwashiorkor, 32 with marasmic kwashiorkor,
70 with marasmus, and 106 age-matched, normally nourished controls.
Aflatoxins were detected more often and at higher concentrations in
sera from children with kwashiorkor than in the other malnourished and
control groups. Aflatoxicol, a metabolite of aflatoxins B1 and B2, was
detected in the sera of children with kwashiorkor and marasmic
kwashiorkor but not in the controls and only once in a marasmic child.
The difference between children with kwashiorkor or marasmic
kwashiorkor and those in the control or marasmus groups was
significant. Urinary aflatoxin was most often detected in children
with kwashiorkor but their mean concentration was lower than in the
other groups. Aflatoxicol was not detected in urine in any group.
These findings suggest either that the children with kwashiorkor have
a greater exposure to aflatoxins or that their ability to transport
and excrete aflatoxins is impaired by the metabolic derangements
associated with kwashiorkor. The presence of aflatoxicol in the sera
of children with kwashiorkor but not in the others suggests a
difference in metabolism between the two groups. Further studies are
needed, and measurement of aflatoxins in the food eaten by these
children is already underway.
Effects of
kwashiorkor malnutrition on measured capillary filtration rate in
forearm.Am
J Physiol. 1992 Feb;262(2 Pt 2):H496-502.
This study
investigated the effects of kwashiorkor malnutrition on blood tissue
fluid exchange by measuring the rate of capillary filtration (CFR) in
response to a 60-mmHg increment in venous pressure in the forearms of
1- to 3-yr-old native African children within the Transkei Homeland.
They were divided into the following subject groups: kwashiorkor
patients (K); kwashiorkor patients who were at various stages of
recovery (RK); marasmus patients (M); patients with edema of
nonkwashiorkor origin (E); and control children (C). Measurements of
CFR were significantly lower in the K subjects compared with any of
the other groups (P less than 0.05), whereas, the RK, M, E, and C
subjects were not significantly different from each other. This latter
finding indicates that the lower CFR of the K patients is reversible
and is not due to malnutrition or edema per se. Measurements of
forearm cutaneous blood flow by laser Doppler flowmetry (LDF) in C and
K subjects showed only a slightly lower value for the K patients (P
greater than 0.20), and there was no relationship between CFR and LDF
for either group (r = 0.073). These results suggest that the lower CFR
of the K patients is not secondary to peripheral vasoconstriction.
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