Nutrition in the Patient with Anorexia and Cachexia

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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

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Protein-Energy Malnutrition

• Two major types
• Marasmus
• Kwashiorkor (AKA Protein Calorie
  Malnutrition)

Heimburger DC, Ard JD. Handbook of Clinical
Nutrition 4/e, 2006
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Marasmus
Heimburger DC, Ard JD. Handbook of Clinical
Nutrition 4/e, 2006
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Kwashiorkor
Heimburger DC, Ard JD. Handbook of Clinical
Nutrition 4/e, 2006
5
Minimum Diagnostic Criteria
Heimburger DC, Ard JD. Handbook of Clinical
Nutrition 4/e, 2006
6
Physiology of Starvation Stress
Heimburger DC, Ard JD. Handbook of Clinical
Nutrition 4/e, 2006
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Metabolic Rate
Normal range
Long CL, et al. JPEN 19793452-6
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Protein Catabolism
Normal range
Long CL. Contemp Surg 19801629-42
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The Course of Protein-Energy Malnutrition
Mild
Severity of PEM
Severely catabolic
Mildly catabolic
Moderate
Severe
Kwashiorkor
Marasmus
Days
Weeks
Months
Years
Heimburger DC, Ard JD. Handbook of Clinical
Nutrition 4/e, 2006
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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 patients main concern is the loss of
  appetite, and fatigue
• She is 57 tall and weighs 67 pounds,
  (BP 90/40, P60, R18, T97.8)

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Case Presentation

• The patients 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.

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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.

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Case Presentation

• The patients 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

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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

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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?

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Refeeding Syndrome

• Patient at risk cachectic/marasmic patient

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
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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.

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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

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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

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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.

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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.