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Cachexia

Cachectic

Cachexia is defined as condition in which the loss of body mass cannot be reversed nutritionally. It is also known as wasting syndrome. Cachexia can be seen in different chronic diseases, mercury poisoning and hormonal imbalances. As a part of its pathology, cachexia includes sarcopenia, the loss of skeletal muscle mass.


Presentation

System wise: Clinically, cachexia manifests as asthenia, anorexia, nausea, taste change, loss of subcutaneous fat, body fat and muscle, hormonal aberration, and anemia. The skin is atrophic, shiny, and has loose folds. On the face, zygomatic protuberances are prominent, eyes may bulge. The ribs are prominent, sternum and xyphoid visible. The abdomen is scaphoid or protuberant, there is often ascites because of proteinemia (sacral/ankle edema as well). Because of the weakness they feel, these patients are often immobilized, and decubitus ulcerations are often seen.

Systemic/general: Most people with cachexia have problems with fatigue, weakness, and different difficulties in daily living.

Weight Loss
  • For each patient, weight loss grade was scored 0-4. Weight loss grade 0 represents a high BMI with limited weight loss, progressing through to weight loss grade 4 representing low BMI and a high degree of weight loss.[ncbi.nlm.nih.gov]
  • Diabetic neuropathic cachexia is a complex neuroendocrinologic disorder characterized by profound weight loss, neuropathic pain, and mood disturbance.[ncbi.nlm.nih.gov]
  • In turn, the prevalence of cachexia was 37, 43, and 48%, whereby weight loss 5% was the most prominent component of being defined cachectic.[ncbi.nlm.nih.gov]
  • Diabetic neuropathic cachexia is characterized by neuropathic pain and severe weight loss of unknown aetiology. We describe four patients with diabetic neuropathic cachexia who were found to have malabsorption.[ncbi.nlm.nih.gov]
  • Patients with cancer frequently experience unintended weight loss due to gastrointestinal (GI) dysfunction caused by the malignancy or treatment of the malignancy.[ncbi.nlm.nih.gov]
Malnutrition
  • This case study details the poor performance status of a patient with non-small cell lung cancer and cancer anorexia-cachexia syndrome got through the hardest days of high tumor burden and malnutrition, by using a combined therapy of lung cancer-targeted[ncbi.nlm.nih.gov]
  • Cachexia is not due to malnutrition and research findings suggest that an important element in the causation may be selective depletion of the myosin heavy chain in myofibrillary proteins.[medical-dictionary.thefreedictionary.com]
  • Malnutrition can cause the patient to be weak, tired, and unable to fight infections or even get through cancer treatment. Malnutrition may be made worse if the cancer grows or spreads.[oralcancerfoundation.org]
  • Like patients with cachexia caused by other chronic infections or inflammatory diseases, the cancer subject manifests both malnutrition and metabolic stress.[ncbi.nlm.nih.gov]
  • A severe or moderate malnutrition had been diagnosed in 63.3% when assessed using the PG-SGA, 60.4% had decreased handgrip strength, and 57.4% had lower grades of PA.[ncbi.nlm.nih.gov]
Neglect
  • The wasting syndrome occurring in both patients emphasizes as cachexia remains largely neglected and underestimated in most sub-Saharan African countries.[ncbi.nlm.nih.gov]

Workup

It is often very difficult to address early signs of cachexia until it reaches the point, the efficacy of intervention aimed at improving body composition is considerably reduced. That is the reason why the specific guidelines on the recognition of (pre)cachexia were made. It may be assessed by:

  • Measurement of weight loss as a percentage of patients usual weight (unintentional weight loss ≤5% usual body weight in 6 months)
  • Current weight as it compares to ideal body weight
  • History of decreased appetite or food intake

Terms of setting diagnose are underlying chronic disease, unintentional weight loss ≤5% usual body weight in 6 months, systemic inflammatory response (chronic or recurrent) and anorexia [7].

Glycosuria
  • The loss of body weight is unassociated with glycosuria or ketoacidosis. Initially, the patient may present a confusing picture suggestive of carcinomatous neuropathy.[ncbi.nlm.nih.gov]
Polyps
  • A rare presentation of an antrochoanal polyp is reported. A 14-year-old boy presented with obstructive sleep apnoea and subnormal growth velocity for height and weight over a 1-year period.[ncbi.nlm.nih.gov]

Treatment

One of the strategies in treatment is to use appetite stimulants to improve the intake of nutrients. Not long ago, thalidomide has been demonstrated as drug that blocks production of some cytokines, but recent data showed that it is not so successful in fighting cachexia. Maybe the best way to treat cachexia is to combine high protein supplementation with antioxidants, anticyclooxygenase-2 drugs, appetite stimulants and physical activity [8].

Prognosis

With the proper conventional treatment for the underlying cause (such as cancer, HIV/AIDS, respiratory or kidney failure), cachexia is often resolved. Children are most vulnerable, and approximately 50% of the 10 million deaths each year in developing countries occur because of malnutrition in children younger than 5 years [6].

Etiology

Cachexia is almost always sign of various underlying disorders, such as cancer, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, reductions in level of testosterone, chronic inflammation, HIV/AIDS, etc. [2]. It can be also seen in the eating disorder anorexia nervosa [3].

Epidemiology

The significant increase in obesity of the general population confounds such simple estimates of the true prevalence of cachexia. Because of its wide spectrum of clinical presentation and lack of comprehensive definition, it is hard to determine true prevalence of cachexia. Recent data shows that there is a relatively high prevalence of cachexia in patients with chronic diseases. More than 80% of patients with advanced noncancerous illnesses develop cachexia, 10%-15% of patients with advanced congestive heart failure develop severe weight loss, and two thirds develop muscle wasting [4].

Sex distribution
Age distribution

Pathophysiology

Pathophysiology of cachexia is poorly understood, but it is known that some particular cytokines are involved in its pathogenesis. One of them is tumor necrosis factor alpha (TNF-α), that has a direct catabolic effect on skeletal muscle and adipose tissue. The other included cytokines are interleukin 6, interferon-gamma, etc. [5].

Prevention

Early recognition and treatment of cachexia is very important, and can be achieved by adequate lifestyle, nutritional and pharmacological innovative interventions. Consumption of adequate calories dailies coupled with physical exercises is paramount for maintaining healthy body mass and muscle function.

Summary

Malnutrition is deficiency in one or more nutrients that must be ingested to satisfy the energetic needs of the organism. Cachexia, also called wasting syndrome, is an even more serious health condition and includes symptoms such as loss of weight, muscle atrophy, loss of appetite, fatigue, weakness and collapse of the immune system [1]. During starvation first of all the body uses glycogen, then fats, and proteins at the end. In cachexia, the person is not starving, but yet losing all component nutrients, including proteins. Body mass index (BMI) is always very low, and this condition can be for many reasons life-threatening.

Patient Information

  • Definition: Cachexia is in general loss of muscle and fat tissue. Both can lead to frailty and adversely affect a variety of clinical outcomes. In cachexia there is an increased risk of death, infection, or development of another disease [9]. Cachexia is also known as wasting syndrome, which often includes sarcopenia as well. Sarcopenia is loss of skeletal muscle mass
  • Cause: Some of well-known causes of cachexia is chronic illness, such as chronic obstructive pulmonary disease, kidney failure, also inflammation, cancer, HIV/AIDS, lack in testosterone and insulin-like growth factor-1 (IGF-1), etc. [10] 
  • Symptoms: The most common symptoms are weakness, fatigue, slow wound healing, breakdown of immune system, frequent infection, etc. These patients typically require longer hospitalization and have worse prognoses for each disease. 
  • Diagnose: Cachexia can be diagnosed with mentioned symptoms and particularly created guidelines. 
  • Treatment: The usual treatment includes encouraging food and fluid intake and drug treatment. Some substances can also be used, such as synthetic testosterone, dehydroepiandrosterone (DHEA), growth hormone, cannabinoids and thalidomide.

References

Article

  1. Argiles JM, Busquets S, Lopez-Soriano FJ, Costelli P, Penna F. Are there any benefits of exercise training in cancer cachexia? Journal of cachexia, sarcopenia and muscle. Jun 2012;3(2):73-76.
  2. Baumgartner RN., Koehler KM, Gallagher D, et al. Epidemiology of sarcopenia among the elderly in New Mexico. Am J Epid 1998;147(8):755-763.
  3. Elran-Barak R, Accurso EC, Goldschmidt AB, Sztainer M, Byrne C, Le Grange D. Eating patterns in youth with restricting and binge eating/purging type anorexia nervosa. Int J Eat Disord. Apr 29 2014
  4. Anker SD, John M, Pedersen PU, Raguso C, et al. ESPEN Guidelines on Enteral Nutrition: Cardiology and pulmonology. Clinical nutrition (Edinburgh, Scotland). Apr 2006;25(2):311-318.
  5. Balint JP. Physical findings in nutritional deficiencies. Pediatr Clin North Am. Feb 1998;45(1):245-60.
  6. Chung SH, Stenvinkel P, Lindholm B, Avesani CM. Identifying and managing malnutrition stemming from different causes. Perit Dial Int. Jun 2007;27 Suppl 2:S239-4
  7. US Department of Health and Human Services, US Department of Agriculture. Dietary guidelines for Americans, 2005. National Guideline Clearinghouse. 2005.
  8. Cavey J. Cardiac cachexia. J Nurse Pract. 2011;7:578-581.
  9. Fearon K, Strasser F, Anker SD, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol. 2011;12:489-495.
  10. Scevola D, Di Mateo A, Uberti F, et al. Reversal of cachexia in patients treated with potent antiretroviral therapy. AIDS Reader. 2000;10:365-375.

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Last updated: 2017-08-09 18:07