Protein-Energie-Malnutrition und Organdysfunktion[1]

Zusammenfassung

Mangelernährung und ihre Auswirkungen sind nicht nur ein Problem der so genannten „Dritten Welt”. Sie können auch unsere Gesellschaft betreffen. In Industrienationen sind vor allem Menschen mit niedrigem sozioökonomischen Status, ältere Menschen und chronisch Kranke gefährdet. Häufig besteht eine Interaktion zwischen Erkrankung und Malnutrition, wobei einerseits die Erkrankung eine Malnutrition zur Folge haben kann und andererseits die Malnutrition den Verlauf einer Erkrankung negativ beeinflussen kann. Eine Mangelernährung wirkt sich, mit unterschiedlichem Schweregrad, auf alle Organsysteme aus und hat sowohl morphologische als auch funktionelle Veränderungen zur Folge. Um durch Mangelernährung hervorgerufene Schäden zu verhindern und einen dadurch aggravierten Krankheitsverlauf zu vermeiden, sind eine umsichtige Prophylaxe, das rechtzeitige Erkennen und Zuordnen von Mangelerscheinungen und eine gezielte Ernährungstherapie erforderlich.

Protein Energy Malnutrition and Organ Dysfunction

Malnutrition and its sequelae are not only a problem of the so-called Third World Countries; our society is also concerned. In the industrialised countries, people of low socio-economic status, the elderly and the chronically ill patients are particularly affected. Frequently, there is an interaction between disease and malnutrition - for example, disease may provoke malnutrition on the one hand, whereas on the other hand malnutrition may adversely affect the course of the disease. Malnutrition has an impact on all internal organic systems of the human body and is the cause of morphological as well as of functional disturbances. In order to prevent damage due to malnutrition, thereby aggravating the course of disease, careful prophylaxis, recognition and classification of deficiencies well in time and specific nutritional therapy are imperative.

1 Nach einem Vortrag bei der 19. Gemeinsamen Jahrestagung der AKE/DGEM, 18. - 20. 5. 2000, in Wien.

Literatur

• 1 Barth C A, Karst H, Petzke K J. Untergewicht und Hungerstoffwechsel. In: Biesalski HK, Fürst P, Kasper H (Hrsg) Ernährungsmedizin. Springer 1999: 271-287
• 2 Pirlich M, Luhmann N, Schütz T, Plauth M, Lochs H. Mangelernährung bei Klinikpatienten: Diagnostik und klinische Bedeutung.  Akt Ernähr Med. 1999;  24 260-266
• 3 Roubenoff R, Heymsfield S B, Kehayias J J, Cannon J G, Rosenberg I H. Standardization of nomenclature of body composition in weight loss.  Am J Clin Nutr. 1997;  66 192-196
• 4 Russell D M, Walker P M, Leiter L A, Sima A A, Tanner W K, Mickle D A, Whitwell J, Marliss E B, Jeejeebhoy K N. Metabolic and structural changes in skeletal muscle during hypocaloric dieting.  Am J Clin Nutr. 1984;  39 503-513
• 5 Symreng T, Larsson J, Schildt B, Wetterfors J. Nutritional assessment reflects muscle energy metabolism in gastric carcinoma.  Ann Surg. 1983;  198 146-150
• 6 Thompson A, Damyanovich A, Madapallimattam A, Mikalus D, Allard J, Jeejeebhoy K N. 31P-nuclear magnetic resonance studies of bioenergetic changes in skeletal muscle in malnourished human adults.  Am J Clin Nutr. 1998;  67 39-43
• 7 Hörl W H, Haag M. Klinische Bedeutung der Hypophosphatämie.  Akt Ernähr Med. 1986;  11 184-189
• 8 Guttridge D C, Mayo M W, Madrid L V, Wang C Y, Baldwin A S. NF-kappaB-induced loss of MyoD messenger RNA: possible role in muscle decay and cachexia.  Science. 2000;  289 2363-2366
• 9 Medina R, Wing S S, Goldberg A L. Increase in levels of polyubiquitin and proteasome mRNA in skeletal muscle during starvation and denervation atrophy.  Biochem J. 1995;  307 631-637
• 10 Lenk S E, Susan P P, Hickson I, Jasionowski T, Dunn W A. Ubiquitinated aldolase B accumulates during starvation-induced lysosomal proteolysis.  J Cell Physiol. 1999;  178 17-27
• 11 Russell D M, Prendergast P J, Darby P L, Garfinkel P E, Whitwell J, Jeejeebhoy K N. A comparison between muscle function and body composition in anorexia nervosa: the effect of refeeding.  Am J Clin Nutr. 1983;  38 229-237
• 12 Russell D M, Leiter L A, Whitwell J, Marliss E B, Jeejeebhoy K N. Skeletal muscle function during hypocaloric diets and fasting: a comparison with standard nutritional assessment parameters.  Am J Clin Nutr. 1983;  37 133-138
• 13 Winick M. Hunger disease. Studies by the jewish physicians in the Warsaw Ghetto. New York, Chichester, Brisbane, Toronto; John Wiley & Sons 1979
• 14 Covinsky K E, Martin G E, Beyth R J, Justice A C, Sehgal A R, Landefeld C S. The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients.  J Am Geriatr Soc. 1999;  47 532-538
• 15 Voit C. Über die Verschiedenheiten der Eiweißzersetzung bei Hungern.  Z Biol. 1866;  2 309-365
• 16 Sedlmair A C. Ueber die Abnahme der Organe, insbesondere der Knochen, beim Hunger.  Z Biol. 1899;  37 25-58
• 17 Kothan S S, Patel T M, Shetalwad A N, Patel T K. Left ventricular mass and function in children with severe protein energy malnutrition.  Int J Cardiol. 1992;  35 19-25
• 18 Heymsfield S B, Bethel R A, Ansley J D, Gibbs D M, Felner J M, Nutter D O. Cardiac abnormalities in cachectic patients before and during nutritional repletion.  Am Heart J. 1978;  95 584-594
• 19 Keys A, Henschel A, Longstreet Taylor H. The size and function of the human heart at rest in semi-starvation and in subsequent rehabilitation.  Am J Physiol. 1947;  150 153-168
• 20 Isner J M, Sours H E, Paris A L, Ferrans V J, Roberts W C. Sudden, unexpected death in avid dieters using the liquid-protein-modified-fast diet. Observations in 17 patients and the role of the prolonged QT interval.  Circulation. 1979;  60 1401-1412
• 21 Swenne I, Larsson P T. Heart risk associated with weight loss in anorexia nervosa and eating disorders: risk factors for QTc interval prolongation and dispersion.  Acta Paediatr. 1999;  88 304-309
• 22 Olowonyo M T, Akinbami F O, Ogunkunle O O, Jaiyesimi F. The electrocardiographic changes in kwashiorkor.  Ann Trop Paediatr. 1993;  13 293-298
• 23 Godfrey K M, Barker D J. Fetal nutrition and adult disease.  Am J Clin Nutr. 2000;  71 S1344-S1352
• 24 Roseboom T J, van Der Meulen J H, Osmond C, Barker D J, Ravelli A C, Schroeder-Tanka J M, van Montfrans G A, Michels R P, Bleker O P. Coronary heart disease after prenatal exposure to the Dutch famine, 1944 - 45.  Heart. 2000;  84 595-598
• 25 Riley D J, Thakker-Varia S. Effect of diet on lung structure, connective tissue metabolism and gene expression.  J Nutr. 1995;  125 S1657-S1660
• 26 Foster J A, Curtiss S W. The regulation of lung elastin synthesis.  Am J Physiol. 1990;  259 L13-23
• 27 Pieters T, Boland B, Beguin C, Veriter C, Stanescu D, Frans A, Lambert M. Lung function study and diffusion capacity in anorexia nervosa.  J Intern Med. 2000;  248 137-142
• 28 Brown R O, Heizer W D. Nutrition and respiratory disease.  Clin Pharm. 1984;  3 152-161
• 29 Sheldon G F, Petersen S R. Malnutrition and cardiopulmonary function: relation to oxygen transport.  J Parenter Enteral Nutr. 1980;  4 376-383
• 30 Roussos C, Macklem P T. The respiratory muscles.  N Engl J Med. 1982;  307 786-797
• 31 Arora N S, Rochester D F. Respiratory muscle strength and maximal voluntary ventilation in undernourished patients.  Am Rev Respir Dis. 1982;  126 5-8
• 32 Hedlund J. Community-acquired pneumonia requiring hospitalisation. Factors of importance for the short- and long-term prognosis.  Scand J Infect Dis Suppl. 1995;  97 1-60
• 33 Chandra R K. Nutrition and the immune system: an introduction.  Am J Clin Nutr. 1997;  66 S460-S463
• 34 Wenisch C, Patruta S, Daxböck F, Krause R, Hörl W H. Effect of age on human neutrophil function.  J Leukoc Biol. 2000;  67 40-45
• 35 Thomason H, Burke V, Gracey M. Impaired gastric function in experimental malnutrition.  Am J Clin Nutr. 1981;  34 1278-1280
• 36 Deitch E A, Winterton J, Li M, Berg R. The gut as a portal of entry for bacteremia. Role of protein malnutrition.  Ann Surg. 1987;  205 681-692
• 37 Katayama M, Xu D, Specian R D, Deitch E A. Role of bacterial adherence and the mucus barrier on bacterial translocation: effects of protein malnutrition and endotoxin in rats.  Ann Surg. 1997;  225 317-326
• 38 van der Hulst R R, von Meyenfeldt M F, van Kreel B K, Thunnissen F B, Brummer R J, Arends J W, Soeters P B. Gut permeability, intestinal morphology, and nutritional depletion.  Nutrition. 1998;  14 1-6
• 39 Ferraris R P, Carey H V. Intestinal transport during fasting and malnutrition.  Annu Rev Nutr. 2000;  20 195-219
• 40 Welsh F K, Farmery S M, MacLennan K, Sheridan M B, Barclay G R, Guillou P J, Reynolds J V. Gut barrier function in malnourished patients.  Gut. 1998;  42 396-401
• 41 Elia M, Goren A, Behrens R, Barber R W, Neale G. Effect of total starvation and very low calorie diets on intestinal permeability in man.  Clin Sci. 1987;  73 205-210
• 42 Carey H V, Hayden U L, Tucker K E. Fasting alters basal and stimulated ion transport in piglet jejunum.  Am J Physiol. 1994;  267 R156-163
• 43 Butzner J D, Brockway P D, Meddings J B. Effects of malnutrition on microvillus membrane glucose transport and physical properties.  Am J Physiol. 1990;  259 G940-946
• 44 Ihara T, Tsujikawa T, Fujiyama Y, Bamba T. Regulation of PepT1 peptide transporter expression in the rat small intestine under malnourished conditions.  Digestion. 2000;  61 59-67
• 45 Inoue Y, Grant J P, Snyder P J. Effect of glutamine-supplemented total parenteral nutrition on recovery of the small intestine after starvation atrophy.  J Parenter Enteral Nutr. 1993;  17 165-170
• 46 Miura S, Tanaka S, Yoshioka M, Serizawa H, Tashiro H, Shiozaki H, Imaeda H, Tsuchiya M. Changes in intestinal absorption of nutrients and brush border glycoproteins after total parenteral nutrition in rats.  Gut. 1992;  33 484-489
• 47 Adibi S A, Allen E R. Impaired jejunal absorption rates of essential amino acids induced by either dietary caloric or protein deprivation in man.  Gastroenterology. 1970;  59 404-413
• 48 Herskovic T. Protein malnutrition and the small intestine.  Am J Clin Nutr. 1969;  22 300-304
• 49 Mehta H C, Saini A S, Singh H, Dhatt P S. Biochemical aspects of malabsorption in marasmus.  Br J Nutr. 1984;  51 1-6
• 50 Nichols B L, Nichols V N, Putman M, Avery S E, Fraley J K, Quaroni A, Shiner M, Sterchi E E, Carrazza F R. Contribution of villous atrophy to reduced intestinal maltase in infants with malnutrition.  J Pediatr Gastroenterol Nutr. 2000;  30 494-502
• 51 Klahr S, Alleyne G A. Effects of chronic protein-calorie malnutrition on the kidney.  Kidney Int. 1973;  3 129-141
• 52 Benabe J E, Martinez-Maldonado M. The impact of malnutrition on kidney function.  Miner Electrolyte Metab. 1998;  24 20-26
• 53 Pullman T N, Alving A S, Dern R J, Landowne M. The influence of dietary protein on specific renal functions in normal man.  J Lab Clin Med. 1954;  44 320-332
• 54 Ichikawa I, Purkerson M L, Klahr S, Troy J L, Martinez-Maldonado M, Brenner B M. Mechanism of reduced glomerular filtration rate in chronic malnutrition.  J Clin Invest. 1980;  65 982-988
• 55 Sraer J D, Sraer J, Ardaillou R, Mimoune O. Evidence for renal glomerular receptors for angiotensin II.  Kidney Int. 1974;  6 241-246
• 56 Paller M S, Hostetter T H. Dietary protein increases plasma renin and reduces pressor reactivity to angiotensin II.  Am J Physiol. 1986;  251 F34-39
• 57 Fernandez-Repollet E, Tapia E, Martinez-Maldonado M. Effects of angiotensin-converting enzyme inhibition on altered renal hemodynamics induced by low protein diet in the rat.  J Clin Invest. 1987;  80 1045-1049
• 58 Parke D V, Ioannides C. The role of nutrition in toxicology.  Annu Rev Nutr. 1981;  1 207-234
• 59 Anderson K E. Influences of diet and nutrition on clinical pharmacokinetics.  Clin Pharmacokinet. 1988;  14 325-346
• 60 Zhang W, Parentau H, Greenly R L, Metz C A, Aggarwal S, Wainer I W, Tracy T S. Effect of protein-calorie malnutrition on cytochromes P450 and glutathione S-transferase.  Eur J Drug Metab Pharmacokinet. 1999;  24 141-147
• 61 Akinyinka O O, Adeyinka A O, Falade A G. The computed axial tomography of the brain in protein energy malnutrition.  Ann Trop Paediatr. 1995;  15 329-333
• 62 Househam K C. Computed tomography of the brain in kwashiorkor: a follow up study.  Arch Dis Child. 1991;  66 623-626
• 63 Benitez-Bribiesca L, De la Rosa-Alvarez I, Mansilla-Olivares A. Dendritic spine pathology in infants with severe protein-calorie malnutrition.  Pediatrics. 1999;  104 e21
• 64 Leyton G B. Effects of slow starvation.  Lancet. 1946;  2 73-79
• 65 Keys A, Brozek J, Henschel A, Mickelsen O, Taylor H L. The biology of human starvation. Minneapolis; University of Minnesota Press 1950
• 66 Gardner J M, Grantham-McGregor S M, Himes J, Chang S. Behaviour and development of stunted and nonstunted Jamaican children.  J Child Psychol Psychiatry. 1999;  40 819-827
• 67 Bonjour J P, Schurch M A, Rizzoli R. Nutritional aspects of hip fractures.  Bone. 1996;  18 139S-144S
• 68 Grisso J A, Kelsey J L, Strom B L, Chiu G Y, Maislin G, O’Brien L A, Hoffman S, Kaplan F. Risk factors for falls as a cause of hip fracture in women. The Northeast Hip Fracture Study Group.  N Engl J Med. 1991;  324 1326-1331
• 69 Vellas B, Baumgartner R N, Wayne S J, Conceicao J, Lafont C, Albarede J L, Garry P J. Relationship between malnutrition and falls in the elderly.  Nutrition. 1992;  8 105-108
• 70 Bastow M D, Rawlings J, Allison S P. Benefits of supplementary tube feeding after fractured neck of femur: a randomised controlled trial.  Nutrition. 1995;  11 323-326
• 71 Delmi M, Rapin C H, Bengoa J M, Delmas P D, Vasey H, Bonjour J P. Dietary supplementation in elderly patients with fractured neck of the femur.  Lancet. 1990;  335 1013-1016
• 72 Geinoz G, Rapin C H, Rizzoli R, Kraemer R, Buchs B, Slosman D, Michel J P, Bonjour J P. Relationship between bone mineral density and dietary intakes in the elderly.  Osteoporos Int. 1993;  3 242-248
• 73 Waldorf H, Fewkes J. Wound healing.  Adv Dermatol. 1995;  10 77-96
• 74 Thomas D R. The role of nutrition in prevention and healing of pressure ulcers.  Clin Geriatr Med. 1997;  13 497-511
• 75 Breslow R. Nutritional status and dietary intake of patients with pressure ulcers: review of research literature 1943 to 1989.  Decubitus. 1991;  4 16-21
• 76 Breslow R A, Hallfrisch J, Guy D G, Crawley B, Goldberg A P. The importance of dietary protein in healing pressure ulcers.  J Am Geriatr Soc. 1993;  41 357-362
• 77 Kotler D P, Tierney A R, Wang J, Pierson R N. Magnitude of body-cell-mass depletion and the timing of death from wasting in AIDS.  Am J Clin Nutr. 1989;  50 444-447

1 Nach einem Vortrag bei der 19. Gemeinsamen Jahrestagung der AKE/DGEM, 18. - 20. 5. 2000, in Wien.