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SERUM PROTEINS IN PROTEIN – ENERGY MALNUTRITION





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SERUM PROTEINS IN PROTEIN – ENERGY MALNUTRITION














ABSTRACT
Serum protein patterns were evaluated in various forms protein energy mal-nutrition (PEM) in sixty Nigerian children aged half a month to seventy eight months. They were classified in four groups: controls (c), marasmus (m), marasmic Kwashiorkor (mk), and Kwashiorkor (k) according to clinical examination and welcome classification. The biuret test (Weischselbaum) and cellulose acetate electrophoresis was used to detect and measure (quantitatively) the levels of total protein, albumin, and four fractions of globumin (alpha1 and2, beta and gamma globulins). Some serum proteins differentiated between the various forms of PEM while some did not allow such differentiation.
















  TABLE OF CONTENTS
Title Page -       -       -       -       -       -       -       -       -       -       i
Declaration      -       -       -       -       -       -       -       -       -       ii
Dedication       -       -       -       -       -       -       -       -       -       iii
Acknowledgement    -       -       -       -       -       -       -       -       iv
Abstract   -       -       -       -       -       -       -       -       -       -       v
Table of Contents     -       -       -       -       -       -       -       -       vi
List of Tables and Figures                -       -       -       -       -       -       vii

CHAPTER ONE
I.            INTRODUCTION
A.   Etiology
B.   Classification
C.   Serum Proteins
II.          LITERATURE REVIEW

CHAPTER TWO
I.            MATERIALS AND METHODS
A.   PEM Patients and Control
B.   Collection of Samples
C.   Total Protein and Albumin Analysis
D.  Cellulose Acetate Electrophoresis
E.   Calculations

CHAPTER THREE
I.            Results
A.   Types
B.   Total Protein
C.   Serum Albumin
D.  Total Globulin

CHAPTER FOUR
I.            Discussion
II.          Conclusion
Reference
Appendix




















LIST OF TABLES AND CHARTS
Table I:         Types of Protein Energy Mal-nutrition seen at University of Port Harcourt Teaching Hospital
Table II:        Serum Proteins in Various types of Protein Energy Mal-nutrition.

FIGURES
Figure I:       Comparison of Mean Total Protein, Albumin and Globulin Concentration in Varying types of Protein Energy Mal-nutrition, as Determined by Biuret Method.
Figure II:      Serum Globulins in Various types of Protein Energy Mal-nutrition.







CHAPTER ONE
I.            INTRODUCTION
The dominant form of mal-nutrition worldwide is called protein energy mal-nutrition (PEM). PEM is a nutritional disease that is common among infants, and it is one of the four most dangerous infantile diseases. This disease has a wide prevalence and embraces conditions such as marasmus, kwashiorkor and marasmic kwashiorkor. PEM is one of many nutritional diseases, and it has a high mortality rate.
A.    ETIOLOGY: PEM is not simply due to a deficiency of protein and energy although these contribute a lot to the disease state (PEM). The environment also contributes to type of mal-nutrition that develops. Poverty plays a big role in etiology of PEM. There could be poverty of the knowledge of adequate diet, poverty of material to feed infant on, and/or poverty of money to use to buy adequate food. High energy and low protein diet is implicated in the etiology of kwashiorkor, while deficient energy intake is implicated in marasmus.
B.    CLASSIFICATION: For the diagnosis of PEM, the Welcome classification of 1970 is relied on. The Welcome classification uses the 50th percentile of the Boston standards as the expected weight for age. Diagnosis of PEM using the Welcome classification is as follows: Children without oedema and weighed between sixty to eighty percent (60 – 80%) of their expected weight for age are classified as being underweight. Children weighing between 60 80% of their expected weight for age, with oedema, are classified as having kwashiorkor. Children without oedema and weighed less than 60% of their expected weight for age are considered to have marasmus. Those children with oedema and weighted less than 60% of their expected weight for age are considered to have marasmus kwashiorkor.
C.    SERUM PROTEINS: Serum proteins simply refer to protein found in the serum. These serum proteins are the serum albumins and globulins. Albumin is present in greater quantity. It is about 60 ± 4% of the total serum protein, with a normal level of about 42 ± 3.5 gm/l, and a range of 35 – 50 gm/l. The molecular weight of albumin is about 66,300, although it varies from 65,000 – 69,000. Albumin has a peptide chain with about 580 amino acid residues. The liver is the source of albumin, but the thyroid gland produces traces of albumin. The diverse functions of albumin are as follows:
i.            Homeostasis through hemodynamic mechanism
ii.          Albumin transports fatty acids, bilirubin, etc.
iii.        Albumin is available in peripheral tissues as a source of amino acid
iv.         Eighty percent of the colloid osmotic pressure of blood is exerted by albumin.
v.           The negative charge of albumin is the main cause of the Donnan effect which contributes to this pressure.
vi.         Albumin is a buffer pool which aids to stabilize the serum calcium, tryptophan, and hormones.
Serum globulin has several fractions which are alpha (), beta (), and gamma (δ) globulin, each of which has specific properties and functions. These three globulin fractions are separated by electrophoresis, although the separation is not into truly homogenous components, but into groups of protein ions of the same net charge and weight. Thus, the  globulin fraction contains  acid glycoprotein,  antifrypsin, and  fetoglobulin. The  globulin fraction contains cerulloplasmin,   macroglobulin, haptoglobin, and group – specific component (Gc) system. The  globulin fraction contains transferrin, hemopexin, macroglobulin, and C – reactive protein. The  globulin fraction is made up of following immunoglobulins, 1gA, 1gM, 1gE, and 1gD. Globulins thus have antiprotease activity, they are transport proteins, and they transport copper, and maintain copper homeostasis in the tissue. Globulins function to prevent undue excretion of iron by the kidney. It prevents damage to kidney by hemoglobin. Globulins transport iron in circulation and unloads it in the reticuloendothelial system. Globulins do bind to free heme in circulation and helps conserve iron by binding heme and disposing it in the liver. Some globulins are called acute phase proteins due to their appearance or increase in acute infections. Globulins also function to inhibit or destroy bacteria; they protect an individual from attack by infective or allergic disease.

II.         LITERATURE REVIEW
Not much information was available before 1960 about the importance of proteins (especially albumin and globulin) in protein – energy mal-nutrition (PEM), although, Trowell (1948) noted that one of the features of kwashiorkor was a low serum protein. This information has been confirmed; in particular, the albumin fraction is depressed in kwashiorkor (McFarlane et al, 1969). Waterlow et al, (1960) noted a fall in total protein concentration in patients with severe PEM. In severe PEM it was also established that the catabolic rate of albumin was reduced by half the rate in recovered patients (Cohen and Hansen, 1962; Picou and Waterlow, 1962). This was confirmed by James and Hay (1968). Brock in 1961 claimed that the concentration of serum albumin was the most sensitive biochemical index of mild impending PEM. In contrast, a study by Waterlow et al, (1960) showed that individual values of serum total protein and albumin were of little diagnostic significance. Whitehead and Dean, (1964) also said serum total protein concentration was relatively insensitive to mal-nutrition. Some South African workers, Truswell et al, (1966) and Wittman et al, (1967), claimed that serum albumin can be used in assessing mal-nutrition and that the concentration was not significantly lower by the time that the children could be considered ‘marginally’ mal-nourished. In a composite classification of severe PEM, Mclaren, Pellett, and Read, (1967) combined different serum albumin concentrations with dermatosis and clinical signs such as oedema, oedema plus dermatosis, hepatomegaly, and hair change. Antia et al, (1968) showed that in kwashiorkor serum transferrin (siderophilin) concentration fell to one fifth of level was a more accurate assessor of severity and response of patients with PEM. Grimble, Sawyer, and Whitehead, (1969) confirmed a study by Widdowson and Whitehead, (1966), which showed that falling serum albumin concentration typified the development of kwashiorkor. But, McFarlane et al, (1969) said that total protein and albumin were of limited use as indices of clinical severity or prognosis of PEM. These workers made other findings which are:
i.            Serum – transferrin provided an accurate assessment of the true nutritional state and seemed to give a clear-cut measure of severity and response to treatment in PEM.
ii.          About half the patients with moderate kwashiorkor had very low total protein, albumin, and transferrin values.
iii.        In deaths from kwashiorkor, hydroxyproline index was severely depressed in all samples tested.
iv.         The study also showed a pattern (from biochemical tests) with kwashiorkor that was distinctly different from the pattern with moderate-to-severe marasmus.
In the same year, Waterlow (1969) said certain mechanisms tend to maintain total circulating mass of albumin when protein supplies are low, thus, a fall in serum albumin concentration is a late event in PEM.
        Whitehead, Frood and Poskitt, (1977) found that album concentration below 2.5 g d1 were clearly pathological, as more that 50% of children in Uganda exhibited a monface with such values. Normal children have serum albumin concentrations above 3.5 g d1 thus, even values between 3.0 and 3.5 g d1 must be regarded as subnormal, and concentration below 3.0 g d1 indicate the onset of pathophysiology (Alleyne et al, 1979).
        Importance of serum albumin measurement got a bonus point when Whitehead and Lunn, (1973) said serum albumin concentration gave the most predictive information of the biochemical measurements in a kwashiorkor endmic area. In the same year, low serum alpha2 () and beta () globulin were said to be one of the various major biochemical changes which are closely related to the pathological abnormalities found later in severe kwashiorkor (Whitehead et al, 1973). Baetl et al, (1974) found high correlation between total serum protein and albumin and felt that total protein measurements could easily replace albumin measurements as a field tool in clinical conditions. Coward, (1975) in Uganda showed that not until albumin concentration fell to values between 25.1 and 27.5 g  serum colloidal osmotic pressure did not fall significantly. At the same time a study by Hay, Whitehead and Spicer, (1975) showed that serum albumin concentration was directly related to mortality; as serum albumin fell from 2.0 to 0.8 g d, mortality rates rose from 3.8 to 62.5 percent. Hay (1975) also said that serum albumin was a much more accurate single index of prognosis in PEM.
        In a study of Nigerian children, Olusi et al, (1975) noted greater reduction in serum albumin concentration the more severe the degree of PEM. These workers also noted a fall in pre-albumin (20.5 ± 5 mg/100 ml for control, 11 ± 2.0 mg/100 ml kwashiorkor, 7.5 mg/100 ml in very severe kwashiorkor, and 13.5 ± 2.5 mg/100 ml in marasmic children); serum transferrin fell from 210 ± 40 mg/100 ml in control to 100 ± 20.5 mg/100 ml in kwashiorkor, in severe cases of kwashiorkor transferrin level fell to 25 mg/100 ml; they also found a fall in serum complement C3 (30 ± 5.5 mg/100 ml in kwashiorkor, and 72 ± 15 mg/100 ml in controls). There was no association between severity of kwashiorkor and complement C4 concentration, and no statistically significant difference between C4 levels in kwashiorkor and marasmus; serum immunoglobulin also showed no correlation with PEM (Olusi et al, 1975).
        Hay et al, (1975) saw the need to include serum – albumin concentration in international classification systems for assessment of PEM, especially kwashiorkor type. Salah Ali Taha, (1979) found that total plasma protein and serum albumin levels were normal in marasmic cases but were below normal in kwashiorkor and marasmic kwashiorkor.
        Shetty et al, (1979) found that thyroxine – binding pre-albumin (TBPA) and retinol – binding protein (RBP) were very sensitive indicators of PEM. Any albumin value is very dependent on the method used for its analysis (Alleyne, Hay, Picou, Stanfield, and Whitehead, 1979).
        In an experiment on deficient diet in healthy monkeys, statically significant fall in total serum proteins and albumin was observed after five weeks of protein deficiency (Tatke and Bazaz – Malik, 1981). In the same study, serum globulins rose significantly at fifteen weeks, and the rise was mainly due to gamma-globulins.
        It is clear from the above that more study is needed in serum proteins especially globulins to see the pattern of globulins in PEM. Such results are likely to be useful in the laboratory diagnosis. Prognosis and monitoring of the treatment is of PEM cases.




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