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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.
), 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.
) 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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