Pathogenesis of and Intervention for Malnutrition in HIV Infection
Donald P. Kotler, M.D.
St. Luke's-Roosevelt Hospital Center
Columbia University College of Physicians and Surgeons
- To review the major pathogenic features underlying malnutrition in HIV infection.
- To review the studies of nutritional support in HIV infection.
Malnutrition is common in HIV-infection and plays an independent and significant role in its morbidity and mortality. Early studies showed weight loss and evidence of protein depletion, while body composition documented depletion of body cell mass in HIV-infected men, with more prominent losses of fat in women. Malnutrition in HIV infection promotes adverse clinical outcomes, including shortened survival and diminished quality of life. The development of malnutrition is multifactorial, varies as a function of disease stage and disease complications, and includes alterations in intake, absorption, or metabolism. Metabolic abnormalities in HIV-infected individuals include elevations in resting energy expenditure (REE), increased protein turnover in clinically ill patients, alterations in fat metabolism, and hypogonadism. HIV infection itself may promote malnutrition, as body cell mass depletion and elevated REE occur in early-stage subjects, weight loss and REE correlate with plasma viral load, and weight gain may occur during antiretroviral therapy. The relative contributions of the various pathogenic mechanisms is uncertain, though two studies have shown that decreased food intake is the major predictor of weight loss and that total energy expenditure is not elevated in systemic infections associated with weight loss.
Several studies have documented weight gain during nutritional support. Increasing caloric intake by nutritional counseling, nutritional formulae, appetite stimulants, and enteral and parenteral tube feedings all may increase caloric intake and body weight. However, these techniques may fail to lead to body cell mass repletion. For this reason, adjunctive therapies for wasting have been applied, including anabolic agents, cytokine inhibitors, and resistance exercise training. The optimal nutritional support for an HIV-infected individual remains to be determined.
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