This week’s case study is about a client who is 83 years of age and is a skilled nursing amenity resident. The patient presented to the facility with generalized lower limb and abdominal edema. From the interaction with the patient, a past history of malabsorption syndrome and poor feeding from lack of dentures was deduced. Thus, a diagnosis of protein malnutrition was arrived at.
Malnutrition is a serious health crisis with a resultant increased risk of morbidity and mortality. Broadly, malnutrition can either be classified into marasmus, which is an inadequate supply of energy to meet the body’s requirement or kwashiorkor which is the supply of adequate energy with insufficient protein intake (McCance et al., 2019). Classification can also be based on the severity, with malnutrition being classified as mild, moderate, or severe.
Protein malnutrition is etiologically multi-factorial. Its causes include inadequate/improper food intake, impaired absorption, increased gastrointestinal loss of nutrients, increased nutritional needs from various stressors, increased protein loss, and inadequate protein synthesis (Dipasquale et al., 2020). This particular patient’s protein malnutrition is likely due to impaired absorption from the history of the maladaptive syndrome and inadequate food intake based on the difficulty feeding attributed to lack of dentures.
Genetics plays a role in the causation of protein malnutrition. Human genetic variations can alter host genes that impact food absorption and metabolism, including proteins through many mechanisms. Some studies have identified nutrition-associated genes that influence macronutrient intake, such as FTO and single-nucleotide polymorphisms genes, which cause reduced protein intake (Duggal et al., 2018). The genetic variation of individuals also determines the gut microbe composition, which may, in turn, contribute to malnutrition.
The patient came to the emergency department presenting with generalized lower limb edema and abdominal edema. Protein malnutrition is typically characterized by low serum albumin levels due to the decreased synthesis and storage of serum proteins. Low albumin levels lead to an imbalance between oncotic pressure and hydrostatic pressure across vascular walls. Albumin contributes to oncotic pressure, which maintains the intravascular fluid within the blood vessels. Its deficiency thus leads to loss of fluid to the extra-vascular spaces and tissues, which presents clinically as edema.
Reduced oncotic pressure due to low serum albumin level leads to edema from extra-vascular movement of intravascular fluid. This results in intravascular volume depletion, leading to hypovolemia and even shock in serious cases. The body responds to this by increasing the antidiuretic hormone levels to replace the depleted intravascular fluid. This is achieved by water retention by the renal system through the action of this hormone.
Antidiuretic hormone is secreted by the posterior pituitary gland. This hormone acts in the distal renal and collecting tubules and leads to water reabsorption by causing the expression of water transport channels. This leads to intravascular fluid repletion. In addition to decreasing the urine output, this hormone also acts on the endothelial cells of blood vessels to cause vasoconstriction in cases of hypotension.
In addition to genetics, several other factors contribute to the development of malnutrition. Aging, for example, has been shown to increase the risk of malnutrition, as is the case with the patient in this study. This is attributed to factors such as lack of dentures, loss of taste, and reduced movement (Besora-Moreno et al., 2020). This leads to reduced food intake with resultant malnutrition. This may necessitate measures such as nutritional support and screening of the elderly population for early diagnosis and interventions.
Besora-Moreno, M., Llauradó, E., Tarro, L., & Solà, R. (2020). Social and Economic Factors and Malnutrition or the Risk of Malnutrition in the Elderly: A Systematic Review and Meta-Analysis of Observational Studies. Nutrients, 12(3), 737. https://doi.org/10.3390/nu12030737
Dipasquale, V., Cucinotta, U., & Romano, C. (2020). Acute Malnutrition in Children: Pathophysiology, Clinical Effects, and Treatment. Nutrients, 12(8), 2413. https://doi.org/10.3390
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