Kwashiorkor in Adults: Clinical Presentation and Management
Yes, kwashiorkor can definitely occur in adults, although it is less commonly recognized than in children. 1 While traditionally associated with pediatric populations in resource-limited settings, kwashiorkor can develop in adults with severe protein malnutrition, particularly in specific clinical scenarios.
Clinical Scenarios Where Adult Kwashiorkor Occurs
Medical Conditions
- Post-bariatric surgery complications: Adults who have undergone procedures like Roux-en-Y gastric bypass may develop kwashiorkor, especially when complicated by short gut syndrome 2
- Malabsorptive disorders: Conditions affecting protein absorption in the gastrointestinal tract
- Severe dietary restriction: Extreme diets lacking adequate protein intake
- Hospitalized patients: Protein malnutrition is the most common form of nutritional deficiency among hospitalized patients in the United States 3
Clinical Presentation in Adults
Characteristic Features
- Peripheral edema: The hallmark sign, often with anasarca (generalized edema)
- Hypoalbuminemia: Significantly reduced serum albumin levels
- Ascites: Accumulation of fluid in the peritoneal cavity
- Dermatological changes:
- "Crazy pavement" dermatosis
- Hypochromotrichia (loss of hair pigment)
- Alopecia
- "Flag sign" in hair (alternating bands of depigmented and normal hair)
- Systemic manifestations:
- Liver disease
- Neurological changes
- Diarrhea
- Weight loss
- Glossitis (inflammation of the tongue) 3
Pathophysiology
The ESPEN guideline on clinical nutrition in liver disease clarifies that kwashiorkor is not simply a protein deficiency disease as previously thought 1. Rather, it involves:
- Overall calorie deficiency 1
- Maladaptation associated with less efficient breakdown of fat and oxidation of fatty acids 1
- Metabolic disturbances that differ from those seen in marasmus (another form of malnutrition) 1
Diagnostic Approach
Laboratory Assessment
- Serum albumin levels (typically <3.5 g/dL)
- Comprehensive metabolic panel
- Micronutrient levels (often multiple deficiencies)
- Directly measured serum osmolality (to assess hydration status) 1
Anthropometric Measurements
- Body Mass Index (BMI)
- Mid-arm muscle circumference
- Skin fold thickness
Screening Tools
- Malnutrition Screening Tool (MST) is recommended for all adults 1
- Royal Free Hospital Nutrition Prioritizing Tool has shown better sensitivity for identifying malnutrition in liver disease patients 1
Management Approach
Nutritional Rehabilitation
- Initial phase: Careful refeeding to avoid refeeding syndrome
- Protein supplementation: Gradual increase in protein intake
- Caloric intake: Ensuring adequate overall calories (approximately 30-35 kcal/kg/day) 1
- Micronutrient replacement: Addressing specific deficiencies
Medical Management
- Fluid and electrolyte balance: Correction of imbalances
- Albumin administration: For severe hypoalbuminemia
- Diuretics: For management of edema
- Treatment of underlying causes: Addressing malabsorption or other primary issues
Multidisciplinary Approach
- Involvement of gastroenterology, nutrition specialists, and pharmacy is crucial for successful outcomes 2
Prevention in High-Risk Adults
- Regular nutritional screening for patients with malabsorptive conditions
- Close monitoring of post-bariatric surgery patients
- Avoidance of extreme dietary restrictions
- Nutritional counseling for patients with chronic conditions affecting absorption
Common Pitfalls in Diagnosis and Management
- Misdiagnosis: Kwashiorkor is often underdiagnosed or misdiagnosed in developed countries 4
- Focusing only on protein: Remember that overall caloric deficiency is a key factor 1
- Aggressive refeeding: Can lead to dangerous refeeding syndrome
- Failure to address underlying causes: Simply treating the nutritional deficiency without addressing the root cause leads to recurrence
In conclusion, while kwashiorkor is less common in adults in developed countries, it should be considered in patients with appropriate risk factors and clinical presentation. A comprehensive approach to diagnosis and management, with attention to both protein and overall caloric needs, is essential for successful treatment.