Nutrition in the Patient with Anorexia and Cachexia

Jeanette N. Keith, M.D.

Associate Professor of Medicine

Departments of Nutrition Sciences and Medicine

University of Alabama at Birmingham

Protein-Energy Malnutrition

Two major types

• Marasmus• Kwashiorkor

(AKA: Protein Calorie Malnutrition)

Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

Marasmus

Clinical setting Decreased energy intake

Time course to develop Months or years

Clinical features Starved appearance

Weight < 80% standard for height

Triceps skinfold < 3 mm

Mid-arm muscle circumference < 15 cm

Laboratory findings Creatinine-height index <60% standard

Clinical course Reasonably preserved responsiveness to short term stress

Mortality Low, unless related to underlying disease

Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

Kwashiorkor

Clinical setting Decreased protein intake during stress state

Time course to develop Weeks

Clinical features Well-nourished appearance

Easy hair pluckability

Edema

Laboratory findings Serum albumin < 2.8 g/dl

TIBC < 200 μg/dl

Lymphocytes < 1500/mm3

Anergy

Clinical course Infections

Poor wound healing, pressure sores, skin breakdown

Mortality High

Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

Minimum

Diagnostic Criteria

Kwashiorkor Marasmus

• Serum albumin < 2.8 g/dl • Triceps skinfold < 3 mm

• At least one of the following:

• Poor wound healing, decubitus ulcers, or skin breakdown

• Easy hair pluckability

• Edema

• Mid-arm muscle circumference < 15 cm

Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

Physiology of Starvation & Stress

Physiologic characteristics Hypometabolic, non-stressed patient (cachectic, marasmic)

Hypermetabolic, stressed patient (kwashiorkor-risk)

Cytokines, catecholamines, glucagon, cortisol, insulin

↓↓ ↑

Metabolic rate ↓↓ ↑Proteolysis, gluconeogenesis ↓↓ ↑Urea excretion ↓↓ ↑Fat catabolism, fatty acid utilization ↑ ↑Adaptation to starvation Normal Abnormal

Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

Metabolic Rate

60

80

100

120

140

160

180

0 10 20 30 40 50

Days

Re

sti

ng

me

tab

oli

sm

(%

of

no

rma

l)

Major burn Sepsis Trauma Partial starvation Total starvation

Long CL, et al. JPEN 1979;3:452-6

Normal range

Protein Catabolism

0

5

10

15

20

25

30

0 10 20 30 40

Days

Nit

rog

en

ex

cre

tio

n (

g/d

ay

)

Major burn Trauma Sepsis Partial starvation Total starvation

Long CL. Contemp Surg 1980;16:29-42

Normal range

The Course of Protein-Energy Malnutrition

Mild

Moderate

Severe

Sev

erit

y o

f P

EM

Days Weeks Months Years

Kwashiorkor MarasmusS

everely catabolic

Mildly catabolic

Heimburger DC, Ard JD. Handbook of Clinical Nutrition 4/e, 2006

Case

Presentation

• 27-year old female with a 35 pound weight loss in the last six months presents to your morning clinic with her mother

• In the last two weeks, she has lost an additional 10 pounds. She reports decreased po intake, mild epigastric discomfort and bloating

• The patient’s main concern is the loss of appetite, and fatigue

• She is 5’7” tall and weighs 67 pounds, (BP 90/40, P60, R18, T97.8)

Case

Presentation

• The patient’s mother calls you at 6 pm stating that her daughter is having palpitations and is on her way to the emergency room.

• The ER staff pages you. Her ECG reveals torsade des pointes and her potassium is 1.9.

• She is admitted to the Cardiology service and you are consulted for feeding recommendations.

Case

Presentation

• What do you recommend now?– Immediate placement of a PICC catheter for TPN

initiation.

– Have the inpatient team place a dobhoff and begin tube feedings

– Call GI procedures to arrange for PEG placement and enteral feedings.

– Call Dietary for a 1600 kcal diet and begin a calorie count

– Intravenous fluids while correcting the potassium and awaiting other lab studies.

Case

Presentation

• The patient’s potassium is now normal but her course has been complicated by recurrent vomiting.

• EGD reveals a decreased gastric motility and a dilated duodenum bulb with normal motility in the second portion of the duodenum.

• What do you recommend next? – Advance her diet to clear liquids– Begin TPN– Place a post-pyloric feeding tube and begin enteral

nutrition

Case

Presentation

• You place a post pyloric feeding tube for enteral nutrition.

• What weight do you use for caloric provision?

– Ideal Body Weight– Actual Weight– Adjusted Body Weight

• How many calories per kilogram per day do you recommend?

– 35-40 kcal/kg/d– 25-30 kcal/kg/d– 15-20 kcal/kg/d– 20-30 kcal/kg/d

Case

Presentation

• On the morning after beginning her enteral feeding, the patient complains of palpitations and pain in her hands.

• On exam, her hands are swollen and she has pedal edema. Pulmonary exam reveals rales.

• Her potassium is now 2.9, phophorus is 1.8 and magnesium is 1.4.

• Diagnosis?

Refeeding

Syndrome

Underlying low cardiac output:

Cardiac atrophy

Low metabolic rate

Predominantly fatty acid utilization

Superimposed demand for

increased CO:

Fluid challenge

Glucose challenge

Increased catecholamines

& metabolic rate

Hypophospha-temia

Heart failure:

Fluid overload

Cardiac & respiratory decompen-

sation

Patient at risk = cachectic/marasmic patient

Case

Presentation

• The patient is admitted to inpatient psychiatry for the treatment of anorexia/bulimia nervosa.

• After 4 weeks on tube feedings, she was successfully transitioned to oral diet.

• At discharge, her weight was 99 pounds.

Selective Refeeding Approaches

• Hypometabolic, cachectic/marasmic patient– Aim = rebuild cautiously to avoid hypophosphatemia & repletion

heart failure

– Refeed gradually with

» a portion of fuel as fat

» ADEQUATE PHOSPHORUS

– Days 1-2 – BEE x 0.8

– Days 3-4 – BEE x 1.0

– Days 4-6 – BEE x 1.1-1.4

– Days 7+ – BEE x 2 if weight gain is desired

Selective Refeeding Approaches

• Hypermetabolic, stressed patient– Aim = Replace catabolic losses

– Refeed aggressively but not excessively

– Can often achieve calorie & protein goals within 48 hours

• Patient with mixed marasmic/kwashiorkor (starved but also stressed)– Metabolism is accelerated by stress

– Therefore, generally feed as you would a patient with kwashiorkor

– But watch carefully for refeeding syndrome

Key Points To Remember• The metabolic response to starvation for the

hypometabolic patient is to reduce their metabolic rate and use fat as the primary fuel source

• Visceral protein stores are preserved in early in the clinical course of the hypometabolic, starved state

• In underweight patients, use the actual body weight to avoid overfeeding.

• Monitor for re-feeding syndrome with oral, enteral or parenteral nutrition.

Take Home Points

• The stressed hypermetabolic patient is more likely to suffer the consequences of underfeeding.

• The starved, unstressed patient is at risk for the complications of overfeeding and rapid re-feeding.

• If protein calorie malnutrition (kwashiorkor-type) predominates, vigorous nutrition therapy is urgent.

• If marasmus predominates, feeding should be more cautious.