Therapy of Cachexia

The energetic basis of wasting in HIV infection may help to explain the pathogenesis of AIDS cachexia and the elements of therapy. Energy balance results from calories introduced and calories expended or not absorbed: resting energy expenditure (REE) is reduced accordingly during weight-loss episodes, but the reduction in energy intake exceeds that of REE because of anorexia and other GI symptoms (Fig. 1).

The parameters most frequently used at the start of nutritional therapy are: weight loss > 10%; albumin value < 3.5 g/dl; reduction of transferrin, creatinine/weight index, vitamins, and microelements; and changes in other indicative indices of nutrition (see Chp. 3.4).

Treatment of identified and reversible causes of body weight loss is essential for the maintenance and/or repletion of weight, but only a combined nutritional-pharmacological approach increasing energy and protein intake can successfully reverse the anorexia-cachexia syndrome of AIDS. In addition, treatment of the malnutrition is a primary medical objective, along with specific therapies aimed at the basic pathology [51]. Among the palliative treatments, besides pain relief, treatment of malnutrition and weight loss perhaps represents m u>

CONTROL HIV+ AIDS

Fig. 1. Resting energy expenditure (REE) and caloric intake in HIV infection. REE increases according to disease progression, while caloric intake becomes insufficient (-17%) to maintain basal needs. OI, opportunistic infections; BW, body weight. (Modified from [52,53])

the most gratifying therapeutic aspect for the patient, giving him or her a tangible feeling of improvement - as anthropometric, biochemical and immunological nutritional parameters normalise - that is immediately visible in the mirror, on the weight scale, and in response to improved physical capabilities [26].

The therapy of cachexia is primarily based on a correct administration of nutrients and drugs. When the first signs of malnutrition appear, prompt nutritional treatment, based on the prescription of a balanced diet containing adequate proteic-caloric, vitamin, and mineral quantities, is highly advisable [54]. As long as the patient is autonomous, the doctor's task is to prescribe a diet that covers the caloric-proteic requirement with respect to ideal weight, basal metabolism, and physical activity, and which attempts to compensate for previous losses. The number of calories that must be supplied can be calculated using the Harris-Benedict formula [55] (Table 1).

Table 1. The Harris-Benedict equation for calculating the number of supplemental calories needed to treat weight loss due to different conditions

Male: 66 + (13.7 x W) + (5 x H) - (6.8 x A) Female: 655 + (9.6 x W) + (1.7 x H) - (4.7 x A)

Adjunctive calories for different pathologies

Male: 66 + (13.7 x W) + (5 x H) - (6.8 x A) Female: 655 + (9.6 x W) + (1.7 x H) - (4.7 x A)

Adjunctive calories for different pathologies

Surgical operation

+ 5%

Trauma

+ 10-

-15%

Complicated trauma

+20-

-50%

Peritonitis

+15

-20%

Minor infections

+ 5

-20%

Severe infections

+40

-60%

W, actual weight (kg); H, height (cm); A, age (years)

W, actual weight (kg); H, height (cm); A, age (years)

Hypercaloric-hyperproteic diets represent the simplest way to increase body weight. Nevertheless, the patient must be able to take in and assimilate a sufficient quantity of nutrients. This is not always possible by natural ways, and in many cases, the patient will require enteral and/or parenteral nutrition, both in hospital and at home [24, 54, 56]. By means of special formulations, this type of nutrition can guarantee the necessary supply of energy, nutrients, vitamins, mineral salts, and enzymes, and thereby normalise the catabolic pathways of metabolism.

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