Protein-energy malnutrition (PEU), formerly referred to as protein-energy malnutrition, is defined as an energy deficit due to a lack of all macronutrients. At the same time consists usually a lack of numerous micronutrients. The PEU can suddenly and acutely (as starvation) or slow progressively occur. The severity ranges from subclinical deficiencies of obvious emaciation with edema, hair loss and skin atrophy to starvation conditions. A number of organ systems are often severely impaired. In diagnostics are laboratory tests, incl. A determination of serum albumin level, performed. To treat the PEU are fluid and electrolyte deficiencies with i.v. Solutions balanced and then gradually the lack of nutrients, if possible orally fed back.
(See also Overview of malnutrition.)
Protein-energy malnutrition (PEU), formerly referred to as protein-energy malnutrition, is defined as an energy deficit due to a lack of all macronutrients. At the same time consists usually a lack of numerous micronutrients. The PEU can suddenly and acutely (as starvation) or slow progressively occur. The severity ranges from subclinical deficiencies of obvious emaciation with edema, hair loss and skin atrophy to starvation conditions. A number of organ systems are often severely impaired. In diagnostics are laboratory tests, incl. A determination of serum albumin level, performed. To treat the PEU are fluid and electrolyte deficiencies with i.v. Solutions balanced and then gradually the lack of nutrients, if possible orally fed back. (See also Overview of malnutrition.) In the industrialized countries is a PEU, although it is not expected common in older, accommodated in homes for the elderly people and patients with diseases that inhibit appetite, digestion, absorption or metabolism of nutrients. In developing countries, it occurs in children who do not consume enough calories or protein to himself. Classification and etiology A PEU is classified as mild, moderate, marked or severe. The category can be determined by dividing the weight is calculated as a percentage of the expectable weight in relation to height according to international standards (normal 90-110%, 85-90% PEU mild, moderately pronounced PEU 75-85%, heavy PEU less than 75 %). PEU may be primary: Caused by inadequate nutrient intake. Secondary: Results of disorders or drugs that interfere with the utilization of nutrients. Primary PEU world enters a primary PEU mostly in children and older people lacking access to nutrients, especially in the elderly depression is a common cause of this is. A PEU can also be caused by fasting or anorexia. Mistreatment of children or the elderly may also be a cause. In children, chronic primary PEU usually has two forms. Marasmus kwashiorkor The disease form depends on the ratio in which protein and non-protein energy sources are available. A hunger state is acute, severe form of primary PEU. Marasmus, also known as the “dry” form of PEU, leading to weight loss and a sweeping reduction of fat and muscle tissue. In developing countries, marasmus is the most common form of PEU in children. Kwashiorkor (also known as wet, edematous or swelling form of PEU) is a risk for premature weaning, which is typically initiated when a sibling is born and is satisfied instead of the older child. Consequently, children with kwashiorkor tend to be older than children who are suffering from marasmus. Kwashiorkor may be due to an acute illness such as gastroenteritis or other infectious diseases, and is likely to occur after the release of cytokines in children who already suffer from PEU. A diet that lacks it as more of protein to energy sources, more likely to cause kwashiorkor as marasmus. Less than marasmus kwashiorkor with certain parts of the world such as rural Africa, the Caribbean and Pacific islands seem connected. In these areas, staple foods such as sweet potatoes, cassava and green bananas contain little protein and plenty of carbohydrates. In kwashiorkor the cell membranes are leaky and allow intravascular fluid and protein leak, so that peripheral edema arise. Both marasmus and kwashiorkor in cell-mediated immunity is weakened, susceptibility to infections therefore increased. Bacterial infections such as pneumonia, gastroenteritis, otitis media, urinary tract infections and sepsis are typical. Infections result in the release of cytokines that cause an anorectic appearance, enhance muscle breakdown and lower serum albumin levels significantly. In the state of hunger is a lack of all nutrients. This condition occurs occasionally, for. However, by fasting or anorexia nervosa, there is usually caused by external influences such as famine or stay away from the Zivilisation.Sekundäre PEU This form is usually caused by the following factors: diseases that affect the gastrointestinal function, disrupt the digestion (z. B. pancreatic insufficiency), the absorption of (z. B. enteritis, enteropathy), or the lymphatic transport of nutrients (z. B. retroperitoneal fibrosis, Milroy’s disease). In the state auszehrender diseases such as AIDS, cancer or COPD and renal failure, the resulting catabolism causes excessive secretion of cytokines with consequent malnutrition by anorexia or cachexia (loss of muscle and fat). In the final stage of heart failure, a cardiac cachexia, a severe form of malnutrition, where the death rate is particularly high may develop. Factors that lead to cardiac cachexia, are a passive congestion (caused by anorexia), edema of the intestinal tract (impairment of absorption) and an increased O2 demand by anaerobic metabolism in advanced disease state. Wasting diseases decrease appetite or weaken the metabolism of nutrients. Conditions that increase the metabolic demands are: infections, hyperthyroidism, pheochromocytoma, other endocrine disorders, burns, trauma, surgery and other serious diseases. Pathophysiology The initial metabolic response is in a declining metabolic rate. In order to provide energy, the body initially draws from fat tissue. Later, however, when these tissues are exhausted, the body needs protein as an energy source, resulting in a negative nitrogen balance. Abdominal organs and muscles are broken down and lose weight. The weight loss of body organs primarily affects the liver and intestine, followed by heart and kidneys. At least he has an effect on the nervous system. Symptoms and signs The symptoms of moderately obvious PEU show up on the body constitution or specific organ systems. Apathy and irritability are typical symptoms. The patient feels weak, the performance decreases. Cognition is weakened, awareness sometimes clouded. Out of a Lactosemangel and a Achlorhydria develop. Often occur diarrhea, which, aggravated by a lack of intestinal Disaccharasen, primarily lactase. The gonadal tissue atrophies. A PEU can lead to loss of libido in women amenorrhea, in both sexes. The massive fat and muscle loss is typical of all forms of PEU. In adult volunteers who fasted 30-40 days, a weight loss of 25% of the initial weight was serious. If the starvation continues, the weight loss in adults can reach 50% in children may be more. The cachexia is used in adults most clearly in parts of the body where fat deposits are normally present. Muscles shrink and bones are facing. The skin becomes thin, dry, inelastic, pale and cold. The hair is dry, falls out easily and is more sparse. Wound healing slows. In the elderly increases the risk of hip fracture and pressure ulcers (bedsores). In the case of acute or chronic severe PEU to heart size and cardiac output, reduce the pulse slows and blood pressure drops. The respiratory rate and vital capacity go back, falling body temperature and sometimes leads to death of the patient. Edema, anemia, jaundice and petechiae arise. Liver, kidney or heart failure may occur. Marasmus is the cause of hunger conditions, weight loss, growth retardation, and substantial reductions in subcutaneous fat and muscles in children. Ribs and facial bones are facing. Loose, thin skin hangs in folds. Kwashiorkor is characterized by peripheral and periorbital edema because of the decrease of serum albumin. The belly is facing because the abdominal muscles are weakened, the gut is stretched, enlarged liver, and ascites is present. The skin appears dry, thin and furrowed, they may be hyperpigmented and covered with fissures, later hypopigmented be grobschuppig and atrophic. The skin on different parts of the body is affected at different times. The hair is thin, reddish-brown or gray. The head hair falls easily from the scalp can eventually become bald, but his eyebrows grow where appropriate excessive. Alternating phases of malnutrition and adequate food supply cause the hair may clearly visible stripes. Affected children are apathetic, but may become very irritated when they are held. food intake is completely absent, this leads to death within 8-12 weeks. Certain symptoms of PEU have during this period is not enough time to develop. Diagnosis The diagnosis is usually based on the history. To determine the severity: body mass index (BMI), serum albumin, total lymphocyte count, CD4 + -Auszählung, serum transferrin for diagnosis of complications and consequences: blood count, electrolytes, urea, glucose, calcium, magnesium, phosphate The diagnosis of protein deficiency malnutrition can be made based on the patient’s history, when the food supply is clearly inadequate. The cause of the inadequate food intake should be elicited especially in children and adolescents. Here, signs of child abuse and anorexia nervosa are to be checked. The physical examination including the measurement of height and weight, inspection of the body fat distribution and anthropometric measurements of the lean body mass. The Body Mass Index (BMI = weight [kg] / [m] 2) is calculated in order to determine the severity. The results confirm the diagnosis in most cases. Clinical Calculator: Body Mass Index (Quetelet’s index) laboratory tests are required, if not clear from the diet history, whether an inadequate calorie intake is given. A determination of plasma albumin, the total number of lymphocytes and CD4 + T lymphocytes, transferrin, and reactions to skin antigens provide information on the severity of the PEU (see Table: Commonly used values ??for determining the severity of protein-energy malnutrition) or confirm borderline cases the diagnosis. Numerous other blood values ??may deviate from the norm, eg. B. to low levels of hormones, vitamins, lipids, cholesterol, prealbumin, insulin growth factor-1, fibronectin and retinol binding protein. With the creatinine and Methylhistidinwerten the stage of muscle loss can be assessed. Since the protein catabolism slows, and the urea of ??the urine decreases. These results often affect the treatment. Values ??commonly used to determine the severity of protein-energy malnutrition measurement Normal Light malnutrition Moderate malnutrition Severe malnutrition pronounced normal weight (%) 90-110 85-90 75-85 <75 Body Mass Index (BMI) 19-24 * 18-18 , 9 16 to 17.9 <16 Serum Albumin (g / dl) 3.5-5.0 3.1-3.4 2.4-3.0 <2.4 Serum transferrin (mg / dl) 220-400 201-219 150-200 <150 lymphocytes total number (per microliter) 2000-3500 1501-1999 800-1500 <800 Index for the delayed hypersensitivity reaction 2 2 1 0 * In the elderly, a BMI can <21 increase the risk of death. The index for the delayed hypersensitivity reaction (delayed hypersensitivity index) determines the in skin tests by an ordinary antigen (eg., By Candida sp. Or Trichophyton sp.) Triggered induration. Induration 0 = <0.5 cm, 1 = 0.5-0.9 cm, 2 = ? 1.0 cm. To determine the causes of suspected secondary PEU, laboratory tests are needed. The C-reactive protein or the soluble interleukin-2 receptor should be determined when the cause of malnutrition is not unique; These measurements indicate whether a Zytokinüberschuss present. Thyroid function should be checked. With further laboratory tests abnormalities can be detected, which are connected to a PEU and require treatment. Serum electrolytes, urea nitrogen, glucose and the levels of calcium, magnesium and phosphate should be measured. The values ??for blood glucose, electrolytes (particularly potassium and sometimes sodium), phosphate, calcium and magnesium are usually low. The urea nitrogen measurement often leads to low values ??when no renal failure is present. Metabolic acidosis may occur. A CBC is normally removed; usually occur a normocytic anemia because of a protein deficiency or microcytic anemia. Stool cultures should be evaluated and tested for ova and parasites, when a severe diarrhea persists, which continues despite successful treatment. Sometimes a urinalysis, a urine or blood culture, a tuberculin test and an X-ray of the chest are performed for the diagnosis of occult infections because weakened malnourished people respond to infections. Forecast children For children is the mortality rate of 5-40%. It is lower when the children are cared for in the ICU and their PEU is less pronounced. The cause of the deadly disease in the first days of treatment is usually of electrolyte deficiencies, sepsis, hypothermia or heart failure. Depressed level of consciousness, jaundice, petechiae, hyponatremia and ongoing diarrhea are considered threatening character, a disappearance of apathy, edema, and anorexia advantageous. Improvement in the condition she is in kwashiorkor faster than in marasmus. The long-time impact of a PEU in children are not fully covered. Some children develop chronic malabsorption and pancreatic insufficiency. Very young children may develop a mild mental disability that lasts at least until they enter school. A long-term cognitive weakness occurs as a function of duration, severity of the PEU and age of onset auf.Erwachsene In adults PEU can cause severe disease states and to death, for. As a progressive weight loss increases the mortality rate of the elderly in nursing homes. In older people, the risks of death or serious disease and simultaneous operations, infections or diseases additionally occurring increase. If no organ failure occurs, treatment is overall successful. Therapy Usually oral intake may avoid lactose (z. B. if persistent diarrhea founded suspicions of lactose intolerance) Supportive measures (eg. As the environment changes, assistance with feeding, orexigenic medication) in children shift food intake to 24-48 h Worldwide is the most important prevention strategy is to alleviate poverty, educate people increased by a healthy diet and to improve public health measures. A mild or of moderate PEU, which includes short-term hunger states count can be treated with preferably orally fed food that restores the nutrient balance. Liquid oral nutritional supplements (usually lactose) are used when solid food can not be adequately digested. Diarrhea often complicate the oral administration, as the intestinal tract in the fasting state transported more likely bacteria in Peyer's patches and thus favors the occurrence of infectious diarrhea. For persistent diarrhea, which suggests a lactose intolerance, yogurt diets are administered rather than milk-based, as patients tolerate lactose intolerance with yogurt. They should also receive a multivitamin supplement. A severe PEU or a longer-term starvation require hospitalization at a fixed diet scheme. Here, fluid and electrolyte abnormalities are primarily corrected and fights infections. (A recent study showed that children benefit from antibiotic prophylaxis.) Then, the focus is to supply macronutrients orally or, if necessary (eg. As for swallowing problems), via a nasogastric tube or PEG (enteral nutrition). Parenteral nutrition is indicated when a severe malabsorption is. Additional therapeutic measures are necessary if individual nutrient deficiencies need to be corrected, which appear with increasing body weight. To avoid nutrient deficiencies, patients should take about twice as many micronutrients like recommend the RDA guidelines until they are fully recovered. Children First, the diseases of malnutrition underlying treat. Children suffer from diarrhea, the food intake by 24 to 48 h is moved in order to avoid that the diarrhea worse; during this interval, the children require oral or i.v. Rehydration. Food portions are given frequently (6 to 12 times / day), but stay on small amounts limited (<100 ml) which does not exceed the gastrointestinal capacity for nutrient absorption. In the first week, formula diets on milk based supplements are added, possibly in increasingly larger amounts; after one week, the full 175 kcal / kg, and 4 g of protein / kg may be administered. Micronutrients should be supplied in double amount of the RDA recommendations using commercial multivitamin supplements. After four weeks, the formula diet can be replaced with whole milk and cod liver oil and solid foods, including eggs, fruit, meat and yeast. The distribution of energy values ??among the macro nutrients should be about 16% protein, 50% fat and 34% carbohydrate. As an example, a combination of skimmed cow's milk powder (110 g), sucrose (100 g), vegetable oil (70 g) and water (900 ml) are used. Even more compositions such as fresh whole milk (full fat) with corn oil and maltodextrin can be used. The milk powder used in the Diet is dissolved in water. The diet formulas following supplements should be added: Magnesium i.m. at a dose of 0.4 meq / kg / day for 7 days vitamins of the B complex in double amount of the RDA guidelines parenterally in the first 3 days, additional vitamin A, phosphorus, zinc, manganese, copper, iodine, fluoride, molybdenum and selenium. Since orally administered iron of children is poorly absorbed with PEU, oral or intramuscular iron supplementation may be necessary. Parents are the necessary nutrition to informieren.Erwachsene the diseases of malnutrition underlying First should be treated. Perform such. As AIDS or cancer in an excessive cytokine production, megestrol acetate or medroxyprogesterone can improve the food supply. However, since these drugs reduce testosterone levels very strong in men and cause a loss of muscle mass, testosterone should be administered. they should be taken only by less than 3 months also because they can lead to renal failure. Patients who are no longer mobile, must obtain supplies of meals and assistance with feeding. A orexigener ingredient as cannabis extract, dronabinol should be prescribed either patients with anorexia when a cause of eating disorder is not clear, or patients end their lives when an anorexic restricts the quality of life. Anabolic steroids (eg. As testosterone enanthate, nandrolone) or growth hormones can have a positive effect (eg., By increases in lean body mass or possibly by improving function) in elderly patients with cachexia secondary to renal failure. Treatment of PEU leads in adults usually results similar to those in children. The oral intake is often limited to small amounts, but it must not be delayed for most adults. Commercially available formula diets for oral administration can be used then. The daily nutrient supply should be 60 kcal / kg and 1.2 to 2 g protein / kg. Are liquid oral supplements administered with solid food, they should be fed at least one hour before meals, so that consumed the meal food intake does not decrease. The treatment of in institutions elderly patients with PEU requires a variety of measures for environmental protection (. Eg attractive design of the dining area) aids in food intake adjusting the diet (eg using appetizing food and calorie supplements between meals.) Treatment of depression and other disorders underlying application orexigener drugs or anabolic steroids alone or in combination the long-term food input via a feeding tube can not be avoided, in demented patients, the use of tube feeding is, however controversial in patients with severe dysphagia. Recent evidence increasingly indicate that little tasty therapeutic food such as low salt, diabetic or low-cholesterol diets should be rejected for residents because these meals can limit food intake and may lead to severe PEU treatment führen.Komplikationen During therapy a PEU complications as the refeeding syndrome occur among the excessive fluid intake, deficiency of electrolytes, hyperglycemia, cardiac arrhythmias, and diarrhea. Diarrhea usually develop temporary slight form, but lead them in patients with severe PEU occasionally severe dehydration or end lethal. The causes of diarrhea (eg. As the sorbitol or Clostridium difficile contained in tube feeding under antibiotic therapy) can be eliminated. An osmotic diarrhea due to excessive calorie intake is rare in adults and should be considered only after exclusion of other causes. Since a PEU restricts the cardiac and renal function, a therapeutic overhydration can lead to intravascular volume overload. One treatment reduced the extracellular potassium and magnesium levels. A depletion of potassium and magnesium deposits can cause cardiac arrhythmias. The increased during treatment Carbohydrate metabolism stimulated insulin secretion, thereby phosphate is transported into the cells. On hypophosphatemia muscle weakness, paresthesias, convulsions, coma or cardiac arrhythmias may follow. Since the phosphate levels can change rapidly during parenteral nutrition, it should be measured regularly. During treatment for PEU endogenous insulin is possibly ineffective, creating a hyperglycemia. This leads to dehydration and hyperosmolarity. It can develop lethal ventricular arrhythmias that may be triggered by a prolonged QT interval. Key points A PEU may be primary (i. E. By a decreased absorption of nutrients caused) or secondary to gastrointestinal disorders, Auszehrungsstörungen or conditions that increase the metabolic demand, responsible. In severe forms of PEU go body fat and eventually lost visceral tissue to which immunity is impaired and slows organ function, sometimes leading to multiple organ failure. For grading the severity of body mass index are used (BMI), serum albumin, total lymphocyte count, CD4 count and serum transferrin. To diagnose complications and consequences, CBC, electrolytes, BUN, glucose, calcium, magnesium and phosphate are determined. In mild cases, a balanced diet is recommended avoiding lactose-containing foods. In severe PEU hospitalization of patients and administration of a controlled diet, a correction of fluid and electrolyte abnormalities, and treatment of infections is done; the most common complications of treatment (refeeding syndrome) include water retention, electrolyte deficits, hyperglycemia, arrhythmia and diarrhea.