Desnutrição e Caquexia na Insuficiência Cardíaca Descompensada e Cardiomiopatia Chagásica: Ocorrência e Associação com Desfechos Hospitalares / Undernutrition and Cachexia in Patients with Decompensated Heart Failure and Chagas Cardiomyopathy: Occurrence and Association with Hospital Outcomes

Resumo Fundamento Problemas nutricionais são comuns em pacientes com insuficiência cardíaca (IC) e estão associados a um prognóstico ruim. É relevante mencionar que algumas populações de pacientes, como os com Doença de Chagas, são normalmente excluídas da maioria das análises. Objetivo Buscamos analisar a ocorrência de desnutrição e caquexia em pacientes com Doença de Chagas durante episódios de IC descompensada (ICD) em comparação a outras etiologias, e investigar a influência desses achados em desfechos hospitalares. Método Realizamos um estudo de série de casos consecutivos com pacientes hospitalizados com ICD. Os pacientes foram submetidos à Avaliação Nutricional Subjetiva Global (ASG), além de medidas antropométricas e laboratoriais, e foram avaliados para a ocorrência de caquexia, baixa massa muscular e força. Estudamos a ocorrência de morte e transplante cardíaco de urgência durante a internação. Resultados Ao todo, 131 pacientes foram analisados e 42 (32,1%) tinham Doença de Chagas. Pacientes com Doença de Chagas apresentavam índice de massa corporal (IMC) menor (22,4 kg/m2 [19,9-25,3] vs. 23,6 kg/m2 [20,8-27,3], p=0,03), maior frequência de desnutrição (76,2% vs 55,1%, p=0,015) e mais ocorrências de morte ou transplante (83,3% vs. 41,6%, p<0,001). Observamos que, dentre os pacientes com etiologia da Doença de Chagas, a ocorrência de morte ou transplante cardíaco esteve associada com desnutrição (3 [42,9%] pacientes com alta hospitalar vs. 29 [82,9%] pacientes que morreram ou receberam transplante cardíaco, P=0,043). Conclusões Ao todo, nossos resultados indicam que pacientes com Doença de Chagas internados com ICD costumam apresentar problemas nutricionais, principalmente desnutrição. É importante mencionar que este achado esteve associado à ocorrência de morte e transplante cardíaco durante a internação.

Abstract Background Nutritional disorders are common among patients with heart failure (HF) and associated with poor prognosis. Importantly, some populations of patients, like the ones with Chagas disease, are frequently excluded from most analyses. Objective We sought to study the occurrence of undernutrition and cachexia in patients with Chagas disease during episodes of decompensated HF (DHF) as compared to other etiologies, and to investigate the influence of these findings on hospital outcomes. Methods We performed a consecutive case series study with patients hospitalized with DHF. Patients underwent the Subjective Global Assessment of nutritional status (SGA), besides anthropometric and laboratorial measures, and were evaluated for the occurrence of cachexia, low muscle mass and strength. We studied the occurrence of death or urgent heart transplantation during hospitalization. Results Altogether, 131 patients were analyzed and 42 (32.1%) had Chagas disease. Patients with Chagas disease had lower Body Mass Index (BMI) (22.4 kg/m2[19.9-25.3] vs. 23.6 kg/m2 [20.8-27.3], p=0.03), higher frequency of undernutrition (76.2% vs 55.1%, p=0.015) and higher occurrence of death or transplant (83.3% vs. 41.6%, p<0.001). We found that, in patients with Chagas etiology, the occurrence of death or cardiac transplantation were associated with undernutrition (3 [42.9%] patients with hospital discharge vs 29 [82.9%] patients with death or heart transplant, p=0.043). Conclusions Taken together, our results indicate that patients with Chagas disease hospitalized with DHF often present with nutritional disorders, especially undernutrition; importantly, this finding was associated with the occurrence of death and heart transplant during hospitalization.

Comprometimento do apetite e fatores associados em pessoas idosas hospitalizadas com câncer / Impairment of appetite and associated factors in older adults hospitalized with cancer

Resumo Objetivo Investigar o comprometimento do apetite em pessoas idosas hospitalizadas com câncer e sua associação com estado nutricional e presença de caquexia. Métodos Estudo transversal realizado com pessoas idosas de ambos os sexos, diagnosticadas com neoplasia maligna, de julho de 2017 a março de 2019 em um hospital universitário. A amostra final foi composta por 90 pacientes. O comprometimento do apetite foi identificado pelo Questionário de Apetite e Sintomas para Pacientes com Câncer (CASQ) e o estado nutricional pela Avaliação Subjetiva Global Produzida pelo Próprio Paciente (ASG-PPP). A presença de caquexia foi avaliada pela perda de peso >5% nos últimos 6 meses; ou índice de massa corporal (IMC) <20 kg/m2 e perda de peso >2%; ou índice de músculo esquelético apendicular consistente com sarcopenia e perda de peso >2%. Resultados Houve predomínio de indivíduos do sexo masculino (56,7%), autodeclarados não brancos (56,7%), com tumores localizados no trato gastrointestinal (75,6%) e mediana de idade de 67 anos. 75,6% dos indivíduos apresentaram comprometimento do apetite, 57,8% suspeita de desnutrição ou desnutrição de algum grau, 54,4% caquexia e 92,2% necessidade de intervenção nutricional. Houve associação entre as categorias do CASQ com estado nutricional (p=0,001) e presença de caquexia (p=0,050). Após análise de regressão logística, a desnutrição permaneceu associada ao comprometimento do apetite [OR: 4,68 (IC 95%: 1,50-14,56), p=0,008]. Conclusão A presença de desnutrição aumentou as chances de comprometimento do apetite, o que reforça a necessidade da triagem e intervenção nutricional precoces, a fim de reduzir e/ou evitar os agravos nutricionais.

Abstract Objective To investigate appetite impairment in older adults hospitalized with cancer and its association with nutritional status and cachexia. Method A cross-sectional study, conducted with older adults men and women diagnosed with malignant neoplasia from July 2017 to March 2019 at a university hospital. The final sample consisted of 90 patients. Appetite was evaluated using the Cancer Appetite and Symptom Questionnaire (CASQ) and nutritional status was determined using the Patient-Generated Subjective Global Assessment (PG-SGA). Presence of cachexia was assessed by weight loss >5% in the last 6 months; or body mass index (BMI) <20 kg/m2 and weight loss >2%; or appendicular skeletal muscle index consistent with sarcopenia and weight loss >2%. Results There was a predominance of male (56.7%) self-declared non-white individuals (56.7%), with tumors in the gastrointestinal tract (75.6%) and median age of 67.0 years. 75.6% of the individuals have impaired appetite, 57.8% suspected malnutrition or malnutrition of some degree, 54.4% cachexia and 92.2% needed nutritional intervention. There was significant association between CASQ categories with nutritional status (p= 0.001) and presence of cachexia (p=0.050). After logistic regression analysis, malnutrition remained associated with impaired appetite assessed by CASQ score [OR: 4.68 (CI 95%: 1.50-14.56), p=0.008] Conclusion The presence of malnutrition increased the chances of appetite impairment, which reinforces the need for early nutritional screening and intervention, in order to reduce and/or avoid nutritional problems.

Role that anorexia and weight loss play in patients with stage IV lung cancer / Papel do binômio anorexia e perda de peso em pacientes com câncer de pulmão em estádio IV

ABSTRACT Objective: To evaluate the prevalence of anorexia and weight loss at diagnosis (pre-treatment), to identify the factors associated with pre-treatment weight loss, and to determine the prognostic role of anorexia and weight loss in the overall survival of patients with stage IV lung cancer. Methods: This was a retrospective observational cohort study. The patients were stratified by the presence/absence of anorexia and of pre-treatment weight loss, which generated a measure composed of four categories, which were the independent variables. Results: Among the 552 patients included in the study, anorexia and pre-treatment weight loss were present in 39.1% and 70.1%, respectively. After adjusting for age, male gender, and Karnofsky performance status, we found that anorexia and tumor size were significantly associated with pre-treatment weight loss. In a Cox multivariate analysis, adjusted for age, male gender and low Karnofsky performance status were found to be independent predictors of worse survival, as was concomitance of anorexia and weight loss. Conclusions: Anorexia and pre-treatment weight loss appear to be relevant problems in the follow-up of patients with advanced (stage IV) lung cancer Specific interventions are of crucial importance in individualized treatment plans, even within the context of palliative care.

RESUMO Objetivo: Avaliar a prevalência de anorexia e perda de peso ao diagnóstico (pré-tratamento), os fatores associados à perda de peso pré-tratamento e o papel prognóstico da anorexia e da perda de peso na sobrevida global de pacientes com câncer de pulmão em estádio IV. Métodos: Estudo de coorte retrospectivo observacional. Os pacientes foram estratificados, dependendo da presença/ausência de anorexia e da presença/ausência de perda de peso pré-tratamento, o que gerou uma medida composta de anorexia e perda de peso de quatro níveis, que foi a variável independente. Resultados: Entre os 552 pacientes incluídos no estudo, as prevalências de anorexia e de perda de peso pré-tratamento foram de 39,1% e 70,1%, respectivamente. Após ajustar para idade, sexo masculino e índice de Karnofsky, a presença de anorexia e o tamanho do tumor foram significativamente associados à perda de peso pré-tratamento. Na análise multivariada de Cox, após ajustar para a idade, as variáveis sexo masculino, presença concomitante de anorexia e perda de peso e índice de Karnofsky reduzido foram preditores independentes de pior probabilidade de sobrevida. Conclusões: O presente estudo demonstrou que a presença de anorexia e de perda de peso pré-tratamento são problemas relevantes no seguimento de pacientes com câncer de pulmão avançado (estádio IV). Intervenções específicas são de crucial importância no plano de assistência individualizada, mesmo dentro da proposta de cuidados paliativos.

Adropin and Irisin in Patients with Cardiac Cachexia / Adropina e Irisina em Pacientes com Caquexia Cardíaca

Abstract Background: Cardiac cachexia is an important predictive factor of the reduction in survival of patients with heart failure with reduced ejection fraction. Objectives: The aims of the present study were to evaluate adropin and irisin levels in cachectic and non-cachectic subjects and the relationships between the levels of these proteins and clinical and laboratory parameters in patients with HFrEF. Methods: The clinical records of patients who were admitted to the cardiology outpatient clinic for heart failure with reduced ejection fraction were screened. Cachectic patients were identified and assigned to the study group (n = 44, mean age, 65.4 ± 11.2 y; 61.4% men). Heart failure with reduced ejection fraction patients without weight loss were enrolled as the control group (n = 42, mean age, 61.0 ± 16.5 y; 64.3% men). The serum adropin and irisin levels of all patients were measured. A p-value < 0.05 was considered significant. Results: Serum adropin and irisin levels were significantly higher in the cachexia group than in the controls (Adropin (ng/L); 286.1 (231.3-404.0) vs 213.7 (203.1-251.3); p < 0.001, Irisin (µg/mL); 2.6 (2.2-4.4) vs 2.1 (1.8-2.4); p = 0.001). Serum adropin and irisin levels were positively correlated with brain natriuretic peptide (BNP) levels and New York Heart Association (NYHA) class and negatively correlated with body mass index (BMI) and serum albumin levels (all p values: < 0.001). In a multivariate analysis, adropin was the only independent predictor of cachexia in the heart failure with reduced ejection fraction patients (OR: 1.021; 95% CI: 1.004−1.038; p = 0.017). Conclusions: The results suggest that adropin and irisin may be novel markers of cardiac cachexia in heart failure with reduced ejection fraction patients. Adropin and irisin are related with the severity of heart failure.

Resumo Fundamento: A caquexia cardíaca é um importante preditor de redução de sobrevida em pacientes com insuficiência cardíaca com fração de ejeção reduzida (ICFER). O objetivo deste estudo foi avaliar os níveis de adropina e irisina em pacientes com ICFER caquéticos e não caquéticos, assim como a relação entre os níveis dessas proteínas e os parâmetros clínicos e laboratoriais nesses pacientes. Objetivos: Os objetivos do presente estudo foram avaliar os níveis de adropina e irisina em indivíduos caquéticos e não caquéticos e as relações entre os níveis dessas proteínas e os parâmetros clínicos e laboratoriais em pacientes com ICFEN. Métodos: Os prontuários de pacientes atendidos no ambulatório de cardiologia para ICFER foram triados. Aqueles com ICFER caquéticos foram identificados e constituíram o grupo de estudo (n = 44; idade média, 65,4 ± 11,2 anos; 61,4% de homens). Aqueles com ICFER e sem perda de peso foram arrolados como grupo controle (n = 42; idade média, 61,0 ± 16,5 anos; 64,3% de homens). Os níveis séricos de adropina e irisina de todos os pacientes foram medidos. Considerou-se significativo um p-valor < 0,05. Resultados: Os níveis séricos de adropina e irisina foram significativamente mais altos nos pacientes caquéticos do que nos controles [adropina (ng/l): 286,1 (231,3-404,0) vs 213,7 (203,1-251,3); p < 0,001; irisina (µg/ml): 2,6 (2,2-4,4) vs 2,1 (1,8-2,4); p = 0,001]. Os níveis séricos de adropina e irisina correlacionaram-se positivamente com os níveis de peptídeo natriurético cerebral (BNP) e a classe funcional da New York Heart Association (NYHA), e negativamente com o índice de massa corporal (IMC) e os níveis séricos de albumina (todos os p-valores: < 0,001). Na análise multivariada, a adropina foi o único preditor independente de caquexia nos pacientes com ICFER (OR: 1,021; IC 95%: 1,004−1,038; p = 0,017). Conclusões: Os resultados sugerem que a adropina e a irisina possam ser novos marcadores de caquexia cardíaca em pacientes com ICFER. Adropina e irisina estão relacionadas com a gravidade da insuficiência cardíaca.

Antioxidant effects of açaí seed ( Euterpe oleracea ) in anorexia-cachexia syndrome induced by Walker-256 tumor

ABSTRACT PURPOSE: To assess antioxidant effects of açaí seed extract on anorexia-cachexia induced by Walker-256 tumor. METHODS: A population of 20 lab rats were distributed into four groups (n=5): Control Group (CG), which only received tumor inoculation. Experimental Group-100 (EG-100), with animals submitted to tumor inoculation and treated with seed extract in a 100 mg / ml concentration through gavage. Experimental Group-200 (EG-200), with animals submitted to tumor inoculation and treated with seed extract in a 200 mg / ml concentration. Placebo Group (GP), which received tumor inoculation and ethanol-water solution. We analyzed proteolysis, lipid peroxidation, tumor diameter and weight. RESULTS: Lipid peroxidation was representative only in the cerebral cortex, where there was more oxidative stress in rats treated with the extract (p = 0.0276). For proteolysis, there was less muscle damage in untreated rats (p = 0.0312). Only tumor diameter in treated rats was significantly lower (p = 0.0200) compared to untreated ones. CONCLUSIONS: The açaí seed extract showed no beneficial effect on the general framework of the cachectic syndrome in lab rats. However, some anticarcinogenic effects were observed in the tumor diameter and weight.

Caquexia associada à insuficiência cardíaca / Heart failure-induced cachexia

Pacientes com insuficiência cardíaca frequentemente desenvolvem estado de caquexia, que constitui fator independente de redução da sobrevida. Caquexia pode ser diagnosticada quando ocorre perda de peso corporal maior que 6% do peso habitual, na ausência de outras doenças. Embora sua fisiopatologia não esteja completamente esclarecida, vários fatores parecem estar envolvidos, como diminuição da ingestão alimentar, anormalidades do trato gastrointestinal, ativação imunológica e neuro-hormonal e alteração da relação entre processos anabólicos e catabólicos. Como não há terapia específica para a caquexia associada à insuficiência cardíaca, o tratamento baseia-se no suporte nutricional, bloqueio neuro-hormonal, controle do edema e anemia e exercícios físicos. Fármacos com propriedades imunomodulatórias e anabólicas encontram-se em investigação clínica e experimental.

Heart failure patients often develop cachexia, which is an independent factor for survival reduction. Cachexia can be diagnosed when there is loss of more than 6% of the body weight, in the absence of other diseases. Even though its pathophysiology has not yet been completely clarified, various factors seem to be involved, such as reduction in food consumption, gastrointestinal tract abnormalities, immunologic and neuro-hormonal activarion and changes in the relationship between anabolic and catabolic processes. Since there is not specific therapy for heart failure-induced cachexia, management is based on nutritional support, neuro-hormonal blockade, control of edema and anemia and exercise. Drugs with anabolic and immunomodulating properties are being evaluated and clinical and non-clinical trials.

Terapia nutricional em crianças e adolescentes com cirrose: uma visão atual / Nutritional therapy in children and adolescents with cirrhosis: current status

A anorexia e o hipermetabolismo são aspectos clínicos importantes em crianças com cirrose. Embora muitas das complicações da cirrose sejam semelhantes àquelas encontradas em adultos, a etiologia e a história natural da progressão da doença e o tratamento clínico em pacientes pediátricos podem ser significativamente diferentes. As alterações metabólicas da doença hepática crônica agravada pela anorexia e desnutrição podem ter implicações negativas no crescimento e desenvolvimento infantil. Crianças com cirrose de evolução progressiva são frequentemente desnutridas e, no entanto, os métodos comumente empregados para avaliação nutricional têm uso limitado nestes pacientes. Mesmo que a importância do estado nutricional sobre o prognóstico destes pacientes seja clara, poucos estudos sobre a terapia nutricional nas hepatopatias da infância têm sido realizados. A avaliação nutricional em crianças com cirrose hepática deve incluir uma completa história clínica e dietética, medidas antropométricas e parâmetros laboratoriais. A recomendação nutricional na cirrose infantil pode variar de acordo com o estado nutricional, idade e quadro clínico. Como a doença hepática crônica em crianças pode impactar significativamente sobre o estado nutricional e consequentemente no crescimento e desenvolvimento, o objetivo deste artigo é revisar os aspectos clínicos e fisiopatológicos envolvidos no diagnóstico e manejo nutricional da cirrose hepática em pacientes pediátricos.

Anorexia and hypermetabolism are disorders of paramount importance in children with cirrhosis. Although many complications caused by cirrhosis in children are similar to those found in adults, the etiologic spectrum and natural history of this disease progression and its clinical management in pediatric patients may be significantly different. The metabolic changes caused by chronic liver disease aggravated by anorexia and malnutrition can affect child growth and development. Malnutrition is common in children with cirrhosis and the methods commonly used for their nutritional assessment are limited. Although the importance of the nutritional status on the prognosis of these patients is clear, there are few studies about nutritional therapy in children with cirrhosis. Nutritional assessment in children with liver cirrhosis should include full clinical and nutritional history, anthropometric measurements, and laboratory parameters. The nutritional recommendation for cirrhosis in children may vary depending on age and nutritional and clinical status. Because chronic liver disease in children may have a significant impact on nutritional status, growth, and development, the objective of this study is to review the clinical and pathophysiological aspects involved in the diagnosis and nutritional management of liver cirrhosis in children.

The role of thalidomide on cachexia during experimental skin carcinogenesis in mice

We investigated the effect of thalidomide on cachexia and TNF-α serum levels during experimental skin carcinogenesis in mice. Female mice were divided into four groups: 1) DMBA (dissolved in acetone) induced tumorigenesis; 2) DMBA and Thalidomide (dissolved in DMSO); 3) DMBA and DMSO; and 4) Acetone. Body weight was measured once a week. Euthanasia was performed 14 weeks later, when blood was collected for the dosage of TNF-α serum levels. Mice with DMBA induced tumorigenesis had a significant loss of body weight when compared to acetone treated animals, starting at the third week and lasting the whole experiment. But there was no difference among Thalidomide treated and the others DMBA control animals, regarding body weight. High TNF-α serum levels were associated with the development of cachexia in mice during the process of experimental skin tumorigenesis. However, there was not a significant difference in the TNF-α serum levels when compared control mice and thalidomide treated mice. These results suggest that thalidomide does not interfere with skin tumorigenesis, cachexia and serum TNF-α levels in Balb/C mice. In addition, high TNF-α serum levels are associated to weight loss during experimental carcinogenesis.

Curso de Reumatologia: aula 2: Importância Clínica da Caquexia Reumatoide / Course of Rheumatology: class 2: Clinical importance of rheumatoid arthistis

A artrite reumatoide é doença autoimune sistêmica de etiologia ainda desconhecida que pode causar destruição de cartilagem e osso. Afeta aproximadamente 1 por cento da população e é duas a três vezes mais frequente nas mulheres do que nos homens. Apesar de agredir predominantemente as articulações, apresenta inúmeras manifestações sistêmicas, entre elas a caquexia - que se manifesta em aproximadamente 66 por cento dos pacientes reumatoides. A caquexia reumatoide é conceituada como perda involuntária de massa celular, predominantemente de músculo esquelético, mas que também ocorre em vísceras e sistema imune. A causa é multifatorial, mas os mecanismos mais importantes são a produção de citocinas, principalmente TNFα e II-1ß, diminuição da ação periférica da insulina e pouca atividade física. Neste artigo discutem-se aspectos relacionados à patogenia, às implicações clínicas e abordagens terapêuticas.

Rheumatoid arthristis is a chronic, systemic, autoimmune disease of unknow etiology that causes destruction of joint cartilage and bone. It affects approximately 1 per cent of the population and predominates among womwn than men. Cachexia, from the Greek "bad condition", generally connotes as state of advanced malnutrition and wasting. However, more recently cachexia has been used to denote the loss of body cell mass which occurs in illness. So rheumatoid cachexia can be defined as an involuntary loss of body cell mass, that predominates in skeletal muscle, and occurs with little or no wegith in the presence of stable or increased fat mass. The etiology is likely multifactorial, and involves excess inflamatory cytokine production, namely excess tumor necrosis factor-α and interleukin-1ß production; reduced peripheral insulin action; and low habitual physical activity. In this article, we evaluate pathogenesis of rheumotoid cachexia, its clinical disclosures and discuss potential therapies.

Abordagem dos efeitos colaterais da cisplatina no estado nutricional dos pacientes com carcinoma de cabeça e pescoço / Approach the side effects of cisplatin on the nutritional status of patients with head and neck carcinoma / Enfoque de los efectos secundarios del cisplatino en el estado nutricional de los pacientes con carcinoma de cabeza y cuello

Introdução: A tendência dos pacientes com carcinoma da cabeça e pescoço (CCP) é cursar com desnutrição e caquexia. Objetivo: Avaliar o estado nutricional (EN) do paciente com CCP antes e durante a quimioterapia com o uso da cisplatina no ambulatório de quimioterapia de um hospital público de São Paulo. Método: Por meio da elaboração de um questionário de efeitos colaterais (DEC) as reações foram avaliadas juntamente com a avaliação antropométrica. Resultados: Apesar da cisplatina, 100% dos pacientes não apresentaram emese, observou-se que 83% faziam radioterapia e quimioterapia associadas, sendo que 50% destes haviam feito cirurgia. Conclusão: Os danos provocados pela cisplatina são menores do que o diagnóstico tardio, que é o verdadeiro responsável pelo prognóstico reservado do paciente de CCP, pois, além de limitar a qualidade de vida, eleva muitos os custos do tratamento.

Introduction: The tendency of patients with carcinoma of the head and neck (CCP) is present with malnutrition and cachexia. Objective: To evaluate the nutritional status (EN) of patients with PBC before and during chemotherapy using cisplatin chemotherapy in the outpatient clinic of a public hospital in São Paulo. Method: Through the development of a questionnaire on side effects (DEC) reactions were evaluated with anthropometric measurements. Results: Although cisplatin, 100% of patients had no emesis was observed that 83% were associated with radiotherapy and chemotherapy, and 50% of these had surgery done. Conclusion: The damage caused by cisplatin are smaller than late diagnosis, which is the true responsible for the prognosis of PBC patients, because in addition to limiting the quality of life raises many of the costs of treatment.

Introducción: La tendencia de los pacientes con carcinoma de cabeza y cuello (CCP) se presenta con la desnutrición y caquexia. Objetivo: Evaluar el estado nutricional (EN) de los pacientes con PBC antes y durante la quimioterapia con cisplatino en la clínica ambulatoria de un hospital público de São Paulo. Método: Mediante el desarrollo de un cuestionario sobre los efectos secundarios (DEC), las reacciones fueron evaluados con las medidas antropométricas. Resultados: Aunque el cisplatino, el 100% de los pacientes no emesis se observó que 83% estaban asociados con la radioterapia y la quimioterapia, y hecho el 50% de estos tenían la cirugía. Conclusión: Los daños causados ​​por el cisplatino es menor que el diagnóstico tardío, que es el responsable de verdad para el pronóstico de los pacientes con CBP, ya que además de limitar la calidad de vida plantea muchos de los costos del tratamiento.

Síndrome de anorexia-caquexia en el paciente oncológico / The cachexia-anorexia syndrome among oncological patients

Se estima que dos terceras partes de los pacientes con cáncer sufren anorexia o pérdida significativa de apetito, lo que conduce a pérdida acentuada de peso y a desnutrición grave (caquexia), una de las principales causas contribuyentes de la muerte. Se ha observado que el síndrome de anorexia-caquexia en cáncer difiere de la desnutrición simple, si bien aún no se conocen los mecanismos exactos que lo ocasionan. Diversas hipótesis proponen que la patogénesis es multicausal, destacándose diversas características del tumor, del huésped y variables del tratamiento. Desafortunadamente, con frecuencia la pérdida acentuada de peso representa para el paciente la progresión del proceso de la enfermedad, lo que puede tener repercusiones significativas en su calidad de vida y en sus interacciones familiares y sociales. Se lleva a cabo una revisión bibliográfica de los procesos etiológicos del síndrome, así como de las posibles medidas terapéuticas y farmacológicas.

Approximately two thirds of cancer patients at advanced stages of the disease suffer from anorexia, which leads to significant weight loss and progressive cachexia, an important factor that contributes to death. It has been observed that cancer cachexia differs from simple starvation, although the exact mechanisms associated with cancer cachexia are not well known. Several theories regarding its pathogenesis point to a complex mixture of tumor, host and treatment variables. Unfortunately, the wasting syndrome also constitutes for the patient, a progression of the cancer process, significantly affecting quality of life and social interactions. Treatable causes should be identified and treated. Knowledge of the mechanisms underlying the effects of caquexia on the patient may play a role in identifying treatment measures targetted to muscle wasting and to maintain body strength. In this article we review the main features and mechanisms of the anorexia-cachexia syndrome in patients with cancer.

Cancer cachexia: pathophysiologic aspects and treatment options.

Cancer cachexia is a syndrome characterized with progressive weight loss and abnormal wasting of fat and muscle tissue, and affects 40 to 85% of all terminally ill patients, accounting more than 20% of all cancer deaths. Current treatment for cancer cachexia principally depends on its prevention rather than reversing the present disease state, and the clinical results are far from being satisfactory. Although the exact mechanism and predisposing factors have yet to be clarified in detail, our growing knowledge about the pathophysiology and biochemical changes considering this life threatening condition should help in development of future therapeutic strategies. In the present paper, the current preclinical and clinical features considering the pathophysiology and treatment of cancer related cachexia are reviewed.

Protein and plasma amino acid metabolism in cancer patients

Proteins present in the human body have numerous functions. Amino acids are the building blocks of proteins used for structural and regulatory functions of body. In cancer cachexia the patients develop anorexia, diminished intake of calories with significant abnormalities in carbohydrate, lipid and protein metabolism and progressive tissue depletion accompanied by weight loss. The gradual loss of host protein stores is central to this process which leads to amino acid imbalance in the blood and some times decreased levels of certain amino acids. Increased urinary amino acids occur in patients of certain cancers. These changes in the amino acid result into altered host defence against cancer and also the therapeutic complications in these patients. Extra nutritional support through gut and total parenteral nutrition [TPN] can alter the tumour host nutrition balance and repletion occur

Pathophysiology of cancer cachexia

Cancer cachexia is a frequent complication observed in patients with malignant tumors. Although several decades have passed since the first focus on the metabolic dysfunction's associated with cancer, few effective therapeutic interventions have been successfully introduced into the medical armamentarium. The present study thoroughly reviews the basic pathophysiology of cancer cachexia and the treatment options already investigated in that field. Experimental and clinical studies were evaluated individually in order to clarify the intricate alterations observed in tumor-bearing patients. The difficulties in introducing sound and effective nutritional support or metabolic manipulation to reverse cancer cachexia are outlined in this review.

Hormônio do crescimento na otimizaçäo do tratamento da insuficiência cardíaca refratária / Growth hormone for optimization of refractory heart failure treatment

It has been reported that growth hormone may benefit selected patients with congestive heart failure. A 63-year-old man with refractory congestive heart failure waiting for heart transplantation, depending on intravenous drugs (dobutamine) and presenting with progressive worsening of the clinical status and cachexia, despite standard treatment, received growth hormone replacement (8 units per day) for optimization of congestive heart failure management. Increase in both serum growth hormone levels (from 0.3 to 0.8 mg/l) and serum IGF-1 levels (from 130 to 300ng/ml) was noted, in association with clinical status improvement, better optimization of heart failure treatment and discontinuation of dobutamine infusion. Left ventricular ejection fraction (by MUGA) increased from 13 percent to 18 percent and to 28 percent later, in association with reduction of pulmonary pressures and increase in exercise capacity (rise in peak VO2to 13.4 and to 16.2ml/kg/min later). The patient was"de-listed" for heart transplantation. Growth hormone may benefit selected patients with refractory heart failure

Serum tumour necrosis factor-alpha and chronic heart failure

Serum tumor necrosis factor-alpha [TNF-alpha] was studied in 84 patients with cachectic chronic heart failure [46 males and 38 females] in addition to 13 healthy volunteers served as controls. The weight, the height, the body mass index, the median circumference, the skin fold thickness and the body fat percentage were used as parameters for the degree of cachexia. Patients were categorized according to underlying etiology of heart failure into group I including 24 patients with rheumatic heart disease [RHD], group II including 20 patients with ischemic heart disease [IHD], group III including 20 patients with cardiomyopathic heart disease and group IV including 20 patients with decompensated corpulmonale. Serum TNF- alpha was significantly higher in all patients [mean +/- SE 125.73 +/- 16.90 pg/ml] than the control group [mean +/- SE 15.94 +/- 2.00 pg/ml], the same level of significance was observed in comparing each group of patients and the control group. When groups of patients were compared with each other, TNF-alpha was statistically higher in group II than group I and group IV. The body fat content percentage was significantly lower in all patients [mean +/- SE 18.2 +/- 0.70] compared with control group [mean +/- SE 22.77 +/- 1.11%]. The findings suggested that the raised level of TNF may play a role in the pathogenesis of cardiac cachexia in patients with chronic heart failure irrespective of their etiology