Why cachexia kills: examining the causality of poor outcomes in wasting conditions

Post-diagnosis adiposity and colorectal cancer prognosis: A Global Cancer Update Programme (CUP Global) systematic literature review and meta-analysis

The adiposity influence on colorectal cancer prognosis remains poorly characterised. We performed a systematic review and meta-analysis on post-diagnosis adiposity measures (body mass index [BMI], waist circumference, waist-to-hip ratio, weight) or their changes and colorectal cancer outcomes. PubMed and Embase were searched through 28 February 2022. Random-effects meta-analyses were conducted when at least three studies had sufficient information. The quality of evidence was interpreted and graded by the Global Cancer Update Programme (CUP Global) independent Expert Committee on Cancer Survivorship and Expert Panel. We reviewed 124 observational studies (85 publications). Meta-analyses were possible for BMI and all-cause mortality, colorectal cancer-specific mortality, and cancer recurrence/disease-free survival. Non-linear meta-analysis indicated a reverse J-shaped association between BMI and colorectal cancer outcomes (nadir at BMI 28 kg/m2). The highest risk, relative to the nadir, was observed at both ends of the BMI distribution (18 and 38 kg/m2), namely 60% and 23% higher risk for all-cause mortality; 95% and 26% for colorectal cancer-specific mortality; and 37% and 24% for cancer recurrence/disease-free survival, respectively. The higher risk with low BMI was attenuated in secondary analyses of RCTs (compared to cohort studies), among studies with longer follow-up, and in women suggesting potential methodological limitations and/or altered physiological state. Descriptively synthesised studies on other adiposity-outcome associations of interest were limited in number and methodological quality. All the associations were graded as limited (likelihood of causality: no conclusion) due to potential methodological limitations (reverse causation, confounding, selection bias). Additional well-designed observational studies and interventional trials are needed to provide further clarification.

Cancer cachexia: biomarkers and the influence of age

Cancer cachexia (Ccx) is a complex metabolic condition characterized by pronounced muscle and fat wasting, systemic inflammation, weakness and fatigue. Up to 30% of cancer patients succumb directly to Ccx, yet therapies that effectively address this perturbed metabolic state are rare. In recent decades, several characteristics of Ccx have been established in mice and humans, of which we here highlight adipose tissue dysfunction, muscle wasting and systemic inflammation, as they are directly linked to biomarker discovery. To counteract cachexia pathogenesis as early as possible and mitigate its detrimental impact on anti-cancer treatments, identification and validation of clinically endorsed biomarkers assume paramount importance. Ageing was recently shown to affect both the validity of Ccx biomarkers and Ccx development, but the underlying mechanisms are still unknown. Thus, unravelling the intricate interplay between ageing and Ccx can help to counteract Ccx pathogenesis and tailor diagnostic and treatment strategies to individual needs.

Predicted clinical and economic burden associated with reduction in access to acute coronary interventional care during the COVID-19 lockdown in two European countries

AIMS

As a consequence of untimely or missed revascularization of ST-elevation myocardial infarction (STEMI) patients during the COVID-19 pandemic, many patients died at home or survived with serious sequelae, resulting in potential long-term worse prognosis and related health-economic implications.This analysis sought to predict long-term health outcomes [survival and quality-adjusted life-years (QALYs)] and cost of reduced treatment of STEMIs occurring during the first COVID-19 lockdown.

METHODS AND RESULTS

Using a Markov decision-analytic model, we incorporated probability of hospitalization, timeliness of PCI, and projected long-term survival and cost (including societal costs) of mortality and morbidity, for STEMI occurring during the first UK and Spanish lockdowns, comparing them with expected pre-lockdown outcomes for an equivalent patient group.STEMI patients during the first UK lockdown were predicted to lose an average of 1.55 life-years and 1.17 QALYs compared with patients presenting with a STEMI pre-pandemic. Based on an annual STEMI incidence of 49 332 cases, the total additional lifetime costs calculated at the population level were £36.6 million (€41.3 million), mainly driven by costs of work absenteeism. Similarly in Spain, STEMI patients during the lockdown were expected to survive 2.03 years less than pre-pandemic patients, with a corresponding reduction in projected QALYs (-1.63). At the population level, reduced PCI access would lead to additional costs of €88.6 million.

CONCLUSION

The effect of a 1-month lockdown on STEMI treatment led to a reduction in survival and QALYs compared to the pre-pandemic era. Moreover, in working-age patients, untimely revascularization led to adverse prognosis, affecting societal productivity and therefore considerably increasing societal costs.

Downregulation of PGC-1α during cisplatin-induced muscle atrophy in murine skeletal muscle

This study aimed to investigate the effects of cisplatin on adenosine triphosphate (ATP) levels, expressions of genes related to mitochondrial oxidative phosphorylation (OXPHOS), and the factors related to mitochondrial biosynthesis in skeletal muscle. Systemic cisplatin administration decreased skeletal muscle mass, skeletal muscle strength, and endurance. The mitochondrial DNA /nuclear DNA ratio was also reduced after treatment with cisplatin. Moreover, among the factors related to mitochondrial biogenesis and function, peroxisome proliferator-activated receptor-γ coactivator-1α (PGC-1α) was significantly downregulated in the cisplatin-treated group. Downregulation of PGC-1α in the skeletal muscle may contribute to muscle weakness during cisplatin-induced muscle atrophy.

Development of a peptide drug restoring AMPK and adipose tissue functionality in cancer cachexia

Cancer cachexia is a severe systemic wasting disease that negatively affects quality of life and survival in patients with cancer. To date, treating cancer cachexia is still a major unmet clinical need. We recently discovered the destabilization of the AMP-activated protein kinase (AMPK) complex in adipose tissue as a key event in cachexia-related adipose tissue dysfunction and developed an adeno-associated virus (AAV)-based approach to prevent AMPK degradation and prolong cachexia-free survival. Here, we show the development and optimization of a prototypic peptide, Pen-X-ACIP, where the AMPK-stabilizing peptide ACIP is fused to the cell-penetrating peptide moiety penetratin via a propargylic glycine linker to enable late-stage functionalization using click chemistry. Pen-X-ACIP was efficiently taken up by adipocytes, inhibited lipolysis, and restored AMPK signaling. Tissue uptake assays showed a favorable uptake profile into adipose tissue upon intraperitoneal injection. Systemic delivery of Pen-X-ACIP into tumor-bearing animals prevented the progression of cancer cachexia without affecting tumor growth and preserved body weight and adipose tissue mass with no discernable side effects in other peripheral organs, thereby achieving proof of concept. As Pen-X-ACIP also exerted its anti-lipolytic activity in human adipocytes, it now provides a promising platform for further (pre)clinical development toward a novel, first-in-class approach against cancer cachexia.

β-Carotene suppresses cancer cachexia by regulating the adipose tissue metabolism and gut microbiota dysregulation

Cancer cachexia is a metabolic disease affecting multiple organs and characterized by loss adipose and muscle tissues. Metabolic dysregulated of adipose tissue has a crucial role in cancer cachexia. β-Carotene (BC) is stored in adipose tissues and increases muscle mass and differentiation. However, its regulatory effects on adipose tissues in cancer cachexia have not been investigated yet. In this study, we found that BC supplementations could inhibit several cancer cachexia-related changes, including decreased carcass-tumor (carcass weight after tumor removal), adipose weights, and muscle weights in CT26-induced cancer cachexia mice. Moreover, BC supplementations suppressed cancer cachexia-induced lipolysis, fat browning, hepatic gluconeogenesis, and systemic inflammation. Altered diversity and composition of gut microbiota in cancer cachexia were restored by the BC supplementations. BC treatments could reverse the down-regulated adipogenesis and dysregulated mitochondrial respiration and glycolysis in adipocytes and colon cancer organoid co-culture systems. Taken together, these results suggest that BC can be a potential therapeutic strategy for cancer cachexia.

LCN2 secreted by tissue-infiltrating neutrophils induces the ferroptosis and wasting of adipose and muscle tissues in lung cancer cachexia

BACKGROUND

Cancer cachexia is a deadly wasting syndrome that accompanies various diseases (including ~ 50% of cancers). Clinical studies have established that cachexia is not a nutritional deficiency and is linked to expression of certain proteins (e.g., interleukin-6 and C-reactive protein), but much remains unknown about this often fatal syndrome.

METHODS

First, cachexia was created in experimental mouse models of lung cancer. Samples of human lung cancer were used to identify the association between the serum lipocalin 2 (LCN2) level and cachexia progression. Then, mouse models with LCN2 blockade or LCN2 overexpression were used to ascertain the role of LCN2 upon ferroptosis and cachexia. Furthermore, antibody depletion of tissue-infiltrating neutrophils (TI-Neu), as well as myeloid-specific-knockout of Lcn2, were undertaken to reveal if LCN2 secreted by TI-Neu caused cachexia. Finally, chemical inhibition of ferroptosis was conducted to illustrate the effect of ferroptosis upon tissue wasting.

RESULTS

Protein expression of LCN2 was higher in the wasting adipose tissue and muscle tissues of experimental mouse models of lung cancer cachexia. Moreover, evaluation of lung cancer patients revealed an association between the serum LCN2 level and cachexia progression. Inhibition of LCN2 expression reduced cachexia symptoms significantly and inhibited tissue wasting in vivo. Strikingly, we discovered a significant increase in the number of TI-Neu in wasting tissues, and that these innate immune cells secreted high levels of LCN2. Antibody depletion of TI-Neu, as well as myeloid-specific-knockout of Lcn2, prevented ferroptosis and tissue wasting in experimental models of lung cancer cachexia. Chemical inhibition of ferroptosis alleviated tissue wasting significantly and also prolonged the survival of cachectic mice.

CONCLUSIONS

Our study provides new insights into how LCN2-induced ferroptosis functionally impacts tissue wasting. We identified LCN2 as a potential target in the treatment of cancer cachexia.

Nutrition care is an integral part of patient-centred medical care: a European consensus

While healthcare is becoming more patient-centred, evidence-based nutrition interventions are still not accessible to all patients with cancer. As nutrition interventions directly improve clinical and socioeconomic outcomes, patient-centred care is not complete without nutrition care. While awareness of the negative impact of malnutrition on clinical outcomes, quality of life, and functional and emotional wellbeing in cancer is growing, there is relatively poor awareness amongst patients, clinicians, policymakers, and payers that nutrition interventions -particularly those begun in the early stages of the disease course- are an effective method for improving such outcomes. The European Beating Cancer Plan recognises the need for a holistic approach to cancer but lacks actionable recommendations to implement integrated nutrition cancer care at member state level. When considering nutrition care as a human right, the impact on quality of life and functional status must be prioritized, as these may be equally as important to patients, especially in advanced cancer where improvements in clinical outcomes such as survival or tumour burden may not be attainable. We formulate actions needed at the regional and the European level to ensure integrated nutrition care for all patients with cancer. The 4 main Take Home Messages are as follows: 1. The goals of Europe's Beating Cancer Plan cannot be achieved without integrating nutrition across the cancer care continuum. 2. Malnutrition negatively impacts clinical outcomes and has socioeconomic consequences for patients and healthcare systems. 3. Championing integrating nutrition care into cancer care is therefore the duty and ethical responsibility of clinicians (Hippocratic Oath-primum non nocere) and 4. Nutrition care is a cost effective, evidence-based therapy.

Detection of Hyponatremia Development in Hemodialysis Patients by Routine Automated Conductivity-Based Monitoring

Predialytic hyponatremia is associated with poor outcome in hemodialysis patients. Hypotonic hyponatremia is the most frequently encountered disorder reflecting mixed disorders combining extracellular fluid overload and free water excess, resulting from the interplay of intermittency of dialysis and diet observance, and likely precipitated by an acute or subacute illness. In this context, hyponatremia requires to be detected and worked up to identify and cure the cause. In this clinical case report, we describe preliminary results of using an online biosensor on a dialysis machine that provides automated predialysis plasma sodium concentration derived from dialysate conductivity measurements. Based on this biosensor, within a 5 year time frame, 11 patients out of more than 130 maintenance hemodialysis patients and over 40,000 dialysis sessions were identified with episodes of predialysis hyponatremia (≤135 mmol/l). In all patients, hyponatremic episodes were indicative of a severe underlying illness associated with fluid overload leading to plasma hypotonicity. Automated online predialysis plasma sodium concentration measurement offers an innovative, reliable, and cost-free tool that permits to detect hyponatremia as marker of an underlying illness development in dialysis patients. The value of this tool in supporting clinical decision-making deserves further studies in a large dialysis population.

Cachexia Is Associated With Adverse Outcomes in Patients Admitted With Heart Failure

Cachexia is often seen in patients with heart failure (HF). This study aimed to examine the association between cachexia and clinical outcomes in patients hospitalized for HF. We extracted all adult cases with a primary diagnosis of HF that were discharged between January and November, identified in the Nationwide Readmissions Database for 2016 through 2019. Exclusion criteria included cases with missing data or a diagnosis of acquired immunodeficiency syndrome, advanced liver disease, end-stage renal disease, chronic lung disease, or malignancy. Appropriate weighting was used to obtain national estimates. Primary outcomes were inpatient mortality, length of stay, and 30-day readmission in patients with HF with cachexia compared with patients with no cachexia. Multivariable logistic regression was used to estimate the association between cachexia and clinical outcomes. Survey procedures were applied using Statistical Analysis Software 9.4. The final analysis included 2,360,307 HF-related hospitalizations. Cachexia was present in about 7% of the study population. A greater percentage of patients with cachexia were female and older than patients without cachexia (52% vs 47% female, the mean age of 77 vs 72 years, respectively). However, after adjusting for demographics and co-morbidities, including coronary artery disease and atrial fibrillation, patients with cardiac cachexia had higher inpatient mortality (odds ratio 3.01, 95% confidence interval 2.88 to 3.15, p <0.001), prolonged hospital stays (9 vs 5 days, p <0.0001), and greater all-cause 30-day readmissions (23% vs 21%, p <0.0001). HF-related cachexia is associated with increased inpatient mortality, greater resource use, and additional healthcare costs.

Pathological features of tissues and cell populations during cancer cachexia

Cancers remain among the most devastating diseases in the human population in spite of considerable advances in limiting their impact on lifespan and healthspan. The multifactorial nature of cancers, as well as the number of tissues and organs that are affected, have exposed a considerable diversity in mechanistic features that are reflected in the wide array of therapeutic strategies that have been adopted. Cachexia is manifested in a number of diseases ranging from cancers to diabetes and ageing. In the context of cancers, a majority of patients experience cachexia and succumb to death due to the indirect effects of tumorigenesis that drain the energy reserves of different organs. Considerable information is available on the pathophysiological features of cancer cachexia, however limited knowledge has been acquired on the resident stem cell populations, and their function in the context of these diseases. Here we review current knowledge on cancer cachexia and focus on how tissues and their resident stem and progenitor cell populations are individually affected.

Identification and management of cancer cachexia in patients: Assessment of healthcare providers' knowledge and practice gaps

BACKGROUND

Cancer cachexia negatively impacts patient outcomes, quality of life and survival. Identification and management of cancer cachexia remains challenging to healthcare professionals (HCPs). The aim of this assessment was to identify current gaps in HCPs' knowledge and practice for identifying and managing adults with cancer-related cachexia. Results may guide development of new educational programmes to close identified gaps and improve outcomes of cancer patients.

METHODS

An international assessment was conducted using a mixed-methods approach including focus group interviews with subject matter experts and an electronic survey of practising HCP. The assessment was led by the Society on Sarcopenia, Cachexia and Wasting Disorders (SCWD) and was supported by in-country collaborating organizations.

RESULTS

A quantitative survey of 58 multiple-choice questions was completed by physicians, nurses dietitians and other oncology HCP (N = 2375). Of all respondents, 23.7% lacked confidence in their ability to provide care for patients with cancer cachexia. Patients with gastrointestinal, head and neck, pulmonary cancers and leukaemia/lymphoma were reported as those at highest risk for cachexia. Only 29.1% of respondents recognized a key criterion of cancer cachexia as >5% weight loss from baseline, but many (14.4%) did not utilize a standardized definition of cancer cachexia. Despite this, most clinicians (>84%) were able to identify causes of weight loss-reduced oral intake, progressive disease, side effects of therapy and disease-related inflammation. Of all respondents, 52.7% indicated newly diagnosed patients with cancer should be screened for weight loss. In practice, 61.9% reported that patient weight was systematically tracked over time, but only 1125 (47.4%) reported they weigh their cancer patients at each visit. Treatment of cachexia focused on increasing the patient's nutritional intake by oral nutritional supplements (64.2%), energy and protein fortified foods (60.3%) and counselling by a dietitian (57.1%). Whereas many respondents (37.3%) considered cachexia inevitable, most (79.2%) believed that an interprofessional team approach could improve care and that use of standardized tools is critical.

CONCLUSIONS

Findings from this international assessment highlight the challenges associated with the care of patients with cancer cachexia, opportunities for interventions to improve patient outcomes and areas of variance in care that would benefit from further analysis.

Identifying cancer cachexia in patients without weight loss information: machine learning approaches to address a real-world challenge

BACKGROUND

Diagnosing cancer cachexia relies extensively on the patient-reported historic weight, and failure to accurately recall this information can lead to severe underestimation of cancer cachexia.

OBJECTIVES

The present study aimed to develop inexpensive tools to facilitate the identification of cancer cachexia in patients without weight loss information.

METHODS

This multicenter cohort study included 12774 patients with cancer. Cachexia was retrospectively diagnosed using Fearon's framework. Baseline clinical features, excluding weight loss, were modeled to mimic a situation where the patient is unable to recall their weight history. Multiple machine learning (ML) models were trained using 75% of the study cohort to predict cancer cachexia, with the remaining 25% of the cohort used to assess model performance.

RESULTS

The study enrolled 6730 males and 6044 females (median age = 57.5 years). Cachexia was diagnosed in 5261 (41.2%) patients and most diagnoses were made based on the weight loss criterion. A 15-variable logistic regression (LR) model mainly comprising cancer types, gastrointestinal symptoms, tumor stage and serum biochemistry indices was selected among the various ML models. The LR model showed good performance for predicting cachexia in the validation data (area under the curve = 0.763, 95% confidence interval=[0.747, 0.780]). The calibration curve of the model demonstrated good agreement between predictions and actual observations (accuracy = 0.714, Kappa = 0.396, sensitivity = 0.580, specificity = 0.808, positive predictive value = 0.679, negative predictive value = 0.733). Subgroup analyses showed that the model was feasible in patients with different cancer types. The model was deployed as an online calculator and a nomogram, and was exported as predictive model markup language to permit flexible, individualized risk calculation.

CONCLUSIONS

We developed a ML model that can facilitate the identification of cancer cachexia in patients without weight loss information, which might improve decision-making and lead to the development of novel management strategies in cancer care.

Deciphering the role of predicted miRNAs of polyomaviruses in carcinogenesis

Human polyomaviruses are relatively common in the general population. Polyomaviruses maintain a persistent infection after initial infection in childhood, acting as an opportunistic pathogen in immunocompromised populations and their association has been linked to carcinogenesis. A comprehensive understanding of the underlying molecular mechanisms of carcinogenesis in consequence of polyomavirus infection remains elusive. However, the critical role of viral miRNAs and their potential targets in modifying the transcriptome profile of the host remains largely unknown. Polyomavirus-derived miRNAs have the potential to play a substantial role in carcinogenesis. Employing computational approaches, putative viral miRNAs along with their target genes have been predicted and possible roles of the targeted genes in many significant biological processes have been obtained. Polyomaviruses have been observed to target intracellular signal transduction pathways through miRNA-mediated epigenetic regulation, which may contribute to cancer development. In addition, BKPyV-infected human renal cell microarray data was coupled with predicted target genes and analysis of the downregulated genes indicated that viruses target multiple signaling pathways (e.g. MAPK signaling pathway, PI3K-Akt signaling pathway, PPAR signaling pathway) in the host as well as turning off several tumor suppression genes (e.g. FGGY, EPHX2, CACNA2D3, CDH16) through miRNA-induced mechanisms, assuring cell transformation. This study provides a conceptual framework for the underlying molecular mechanisms involved in the course of carcinogenesis upon polyomavirus infection.

Investigating effects of sodium beta-hydroxybutyrate on metabolism in placebo-controlled, bilaterally infused human leg with focus on skeletal muscle protein dynamics

Systemic administration of beta-hydroxybutyrate (BHB) decreases whole-body protein oxidation and muscle protein breakdown in humans. We aimed to determine any direct effect of BHB on skeletal muscle protein turnover when administered locally in the femoral artery. Paired design with each subject being investigated on one single occasion with one leg being infused with BHB and the opposing leg acting as a control. We studied 10 healthy male volunteers once with bilateral femoral vein and artery catheters. One artery was perfused with saline (Placebo) and one with sodium-BHB. Labelled phenylalanine and palmitate were used to assess local leg fluxes. Femoral vein concentrations of BHB were significantly higher in the intervention leg (3.4 (3.2, 3.6) mM) compared with the placebo-controlled leg (1.9 (1.8, 2.1) mM) with a peak difference of 1.4 (1.1, 1.7) mM, p < 0.0005. Net loss of phenylalanine for BHB vs Placebo -6.7(-10.8, -2.7) nmol/min vs -8.7(-13.8, -3.7) nmol/min, p = 0.52. Palmitate flux and arterio-venous difference of glucose did not differ between legs. Under these experimental conditions, we failed to observe the direct effects of BHB on skeletal muscle protein turnover. This may relate to a combination of high concentrations of BHB (close to 2 mM) imposed systemically by spillover leading to high BHB concentrations in the saline-infused leg and a lack of major differences in concentration gradients between the two sides-implying that observations were made on the upper part of the dose-response curve for BHB and the relatively small number of subjects studied.

Prognostic Value of the Controlling Nutritional Status (CONUT) Score in Patients at Dialysis Initiation

Protein-energy wasting (PEW) is common in patients with chronic kidney disease (CKD), and affects their prognosis. The Controlling Nutritional Status (CONUT) score is a nutritional screening tool calculated using only blood test data. This study aimed to investigate the prognostic value of CONUT score in patients just initiating dialysis. A total of 311 CKD patients who stably initiated dialysis were enrolled. Only 27 (8.7%) patients were classified as having normal nutritional status. The CONUT score was also independently correlated with elevated C-reactive protein levels (β = 0.485, p < 0.0001). During the median follow-up of 37 months, 100 patients (32.2%) died. The CONUT score was an independent predictor of all-cause mortality (adjusted hazard ratio 1.13, 95% confidence interval 1.04−1.22, p < 0.0024). As model discrimination, the addition of the CONUT score to a prediction model based on established risk factors significantly improved net reclassification improvement (0.285, p = 0.028) and integrated discrimination improvement (0.025, p = 0.023). The CONUT score might be a simplified surrogate marker of the PEW with clinical utility and could predict all-cause mortality, in addition to improving the predictability in CKD patients just initiating dialysis. The CONUT score also could predict infectious-disease mortality.

Tumor cell anabolism and host tissue catabolism-energetic inefficiency during cancer cachexia

Cancer-associated cachexia (CC) is a pathological condition characterized by sarcopenia, adipose tissue depletion, and progressive weight loss. CC is driven by multiple factors such as anorexia, excessive catabolism, elevated energy expenditure by growing tumor mass, and inflammatory mediators released by cancer cells and surrounding tissues. In addition, endocrine system, systemic metabolism, and central nervous system (CNS) perturbations in combination with cachexia mediators elicit exponential elevation in catabolism and reduced anabolism in skeletal muscle, adipose tissue, and cardiac muscle. At the molecular level, mechanisms of CC include inflammation, reduced protein synthesis, and lipogenesis, elevated proteolysis and lipolysis along with aggravated toxicity and complications of chemotherapy. Furthermore, CC is remarkably associated with intolerance to anti-neoplastic therapy, poor prognosis, and increased mortality with no established standard therapy. In this context, we discuss the spatio-temporal changes occurring in the various stages of CC and highlight the imbalance of host metabolism. We provide how multiple factors such as proteasomal pathways, inflammatory mediators, lipid and protein catabolism, glucocorticoids, and in-depth mechanisms of interplay between inflammatory molecules and CNS can trigger and amplify the cachectic processes. Finally, we highlight current diagnostic approaches and promising therapeutic interventions for CC.

Correlation of Patient Generated-subjective Global Assessment with Serum C-reactive Protein Level in Stage I–IV Head-and-neck Cancer

AIM: This study aims to identify the correlation between patient generated-subjective global assessment (PG-SGA) with serum C-reactive protein (CRP) to be used to predict inflammation and prevent cachexia in head-and-neck cancer patients. METHODS: This was a cross-sectional study using 51 patients with inclusion criteria of patients diagnosed with head-and-neck cancer irrespective of stage, age ≥18 years old, had not received treatments of radiotherapy, chemotherapy, and surgery. The statistical analysis performed was Kolmogorov–Smirnov normality test, bivariate analysis by Spearman test, and linear regression analysis. RESULTS: As many as 64.7% of the patients had PG-SGA score ≥9 (average PG-SGA score 11.7 ± 6.2). The CRP median value was 6.4 (0.4–170.4) mg/L. There was a statistically significant positive but weak correlation between PG-SGA score with serum CRP (r = 0.372 and p = 0.007) and a significant linear relationship (r2 = 0.201). CONCLUSIONS: Malnutrition risk assessment using PG-SGA showed a high prevalence of malnutrition risk in head-and-neck cancer patients. PG-SGA score is correlated with serum CRP level. Further studies are needed to confirm the result of this study.

The Effect of Cannabis-Based Medicine in the Treatment of Cachexia: A Systematic Review and Meta-Analysis

Background: Cachexia is a prevalent condition associated with underlying chronic disease. Wasting of skeletal muscle and adipose tissue loss in cachectic patients is associated with higher rates of disability, reduced quality of life (QoL), and worse prognosis. There is a large unmet need to develop strategies to treat cachexia as there are currently no standardized guidelines in the management of cachexia. Activation of endogenous cannabinoid receptors, through exogenous cannabinoids, has demonstrated potential in increasing appetite, reducing catabolism, and has shown anti-inflammatory properties. Since no single pharmacological agent is currently recommended for use in cachexia, the potential of cannabinoids as an appetite stimulant warrants further research and assessment of current evidence. Objective: This review aims to evaluate the evidence for the efficacy of cannabis-based medicinal products, against placebo and other active treatments, in anorexia-cachexia syndrome in improving appetite, weight, and QoL. Methods: A literature search of the Medline, EMBASE, CENTRAL, and the Web of Science Core Collection, for articles published up to February 2020, was conducted. All randomized controlled trials comparing the use of cannabis-based medicine versus placebo/active treatments for patients with cachexia were screened. The quality of evidence in included studies was assessed using the GRADE framework and any risk of bias was judged using the Cochrane risk of bias tool. Results: A total of five studies, encompassing 934 participants, were found to be eligible. The pooled group effect size for change in appetite was -1.79 (95% confidence interval: -3.77 to 0.19) favoring the control group (p=0.08). Additionally, no significant difference for weight change or change in QoL for cannabinoids versus placebo/other treatment was observed. The quality of evidence for all five studies was assessed to be low. Conclusion: There is a lack of high-quality evidence to recommend the use of cannabinoids in the treatment of cachexia. Given the limited available pharmacological options for cachexia and the potential for cannabinoids to increase appetite and alter the immune system, further research is needed before clinical recommendations on the pharmacological management of cachexia can be made.

Association of circulating PLA2G7 levels with cancer cachexia and assessment of darapladib as a therapy

BACKGROUND

Cancer cachexia (CCx) is a multifactorial wasting disorder characterized by involuntary loss of body weight that affects many cancer patients and implies a poor prognosis, reducing both tolerance to and efficiency of anticancer therapies. Actual challenges in management of CCx remain in the identification of tumour-derived and host-derived mediators involved in systemic inflammation and tissue wasting and in the discovery of biomarkers that would allow for an earlier and personalized care of cancer patients. The aim of this study was to identify new markers of CCx across different species and tumour entities.

METHODS

Quantitative secretome analysis was performed to identify specific factors characteristic of cachexia-inducing cancer cell lines. To establish the subsequently identified phospholipase PLA2G7 as a marker of CCx, plasma PLA2G7 activity and/or protein levels were measured in well-established mouse models of CCx and in different cohorts of weight-stable and weight-losing cancer patients with different tumour entities. Genetic PLA2G7 knock-down in tumours and pharmacological treatment using the well-studied PLA2G7 inhibitor darapladib were performed to assess its implication in the pathogenesis of CCx in C26 tumour-bearing mice.

RESULTS

High expression and secretion of PLA2G7 were hallmarks of cachexia-inducing cancer cell lines. Circulating PLA2G7 activity was increased in different mouse models of CCx with various tumour entities and was associated with the severity of body wasting. Circulating PLA2G7 levels gradually rose during cachexia development. Genetic PLA2G7 knock-down in C26 tumours only partially reduced plasma PLA2G7 levels, suggesting that the host is also an important contributor. Chronic treatment with darapladib was not sufficient to counteract inflammation and tissue wasting despite a strong inhibition of the circulating PLA2G7 activity. Importantly, PLA2G7 levels were also increased in colorectal and pancreatic cancer patients with CCx.

CONCLUSIONS

Overall, our data show that despite no immediate pathogenic role, at least when targeted as a single entity, PLA2G7 is a consistent marker of CCx in both mice and humans. The early increase in circulating PLA2G7 levels in pre-cachectic mice supports future prospective studies to assess its potential as biomarker for cancer patients.

Dietary Potassium Intake and Mortality in a Prospective Hemodialysis Cohort

OBJECTIVES

Among hemodialysis patients, clinical practice guidelines recommend dietary potassium restriction given concerns about potential hyperkalemia leading to malignant arrhythmias and mortality. However, there are sparse data informing recommendations for dietary potassium intake in this population. We thus sought to examine the relationship between dietary potassium intake and death risk in a prospective cohort of hemodialysis patients.

DESIGN AND METHODS

Among 415 hemodialysis patients from the prospective "Malnutrition, Diet, and Racial Disparities in Chronic Kidney Disease" cohort recruited across 16 outpatient dialysis clinics, information regarding dietary potassium intake was obtained using Food Frequency Questionnaires administered over October 2011 to March 2015. We first examined associations of baseline dietary potassium intake categorized as tertiles with mortality risk using Cox regression. We then examined clinical characteristics associated with low dietary potassium intake (defined as the lowest tertile) using logistic regression.

RESULTS

In expanded case-mix Cox analyses, patients whose dietary potassium intake was in the lowest tertile had higher mortality (ref: highest tertile) (adjusted hazard ratio 1.74, 95% confidence interval 1.14-2.66). These associations had even greater magnitude of risk following adjustment for laboratory and nutritional covariates (adjusted hazard ratio 2.65, 95% confidence interval 1.40-5.04). In expanded case-mix restricted cubic spline analyses, there was a monotonic increase in mortality risk with incrementally lower dietary potassium intake. In expanded case-mix logistic regression models, female sex; higher serum bicarbonate; and lower dietary energy, protein, and fiber intake were associated with low dietary potassium intake.

CONCLUSIONS

In a prospective cohort of hemodialysis patients, lower dietary potassium intake was associated with higher mortality risk. These findings suggest that excessive dietary potassium restriction may be deleterious in hemodialysis patients, and further studies are needed to determine the optimal dietary potassium intake in this population.

Effects of Testosterone Treatment on Quality of Life in Patients With Chronic Kidney Disease

Testosterone deficiency (TD) is common and impairs quality of life (QoL) in patients with chronic kidney disease (CKD). However, there are no studies about whether testosterone replacement therapy (TRT) can improve QoL in patients with CKD. Therefore, we investigated the effect of TRT on the QoL of patients with CKD and confirmed the safety of TRT. Twenty-five male patients with stages III–IV CKD whose serum testosterone levels were <350 ng/dl (TD) were enrolled and treated with testosterone gel for 3 months (group II). Age-matched controls with stages III–IV CKD and TD (group I) were recommended to exercise for the same period. Before and after the treatment, the BMI and handgrip strength were checked, serological tests were performed, and questionnaires were administered in both groups. Compared to baseline, there was no significant difference in serum testosterone levels, scores of the 36-Item Short Form Health Survey (SF-36), Aging Males’ Symptoms Scale (AMS), and International Prostate Symptom Score (IPSS), and grip strength in group I after 3 months. In group II, a significant increase in testosterone, hemoglobin (Hb), and hematocrit (Hct) was observed, and grip strength significantly increased after TRT. Significant improvement in scores of SF-36, AMS, and IPSS was also confirmed after TRT in group II. There was a significant difference in testosterone, Hb, Hct, grip strength, and scores of SF-36, AMS, and IPSS between the two groups after 3 months. The patients in group II showed positive results and continued with TRT. Therefore, we conclude that TRT safely improves the QoL and TD symptoms in patients with moderate-to-severe CKD.

Efficacy of intradialytic amino acids on nutritional status in children with stage 5 chronic kidney disease

BACKGROUND

Protein energy wasting (PEW) is a common cause of morbidity and mortality in patients with stage 5 chronic kidney disease (CKD 5). Intradialytic parenteral nutrition (IDPN) has been used as a therapy for preventing and treating PEW in children with CKD 5 when other conventional modalities fail. However, not enough data is available to define its effectiveness in treating malnutrition in children. This study aims to investigate potential benefits of IDPN in Egyptian children with CKD 5.

METHODS

In this prospective, placebo-controlled, parallel-group single blinded study, we enrolled 50 CKD 5 patients; 25 patients (intervention group) received intravenous amino acids (KIDIMN), while 25 patients (control group) received normal saline as placebo, each given during regular dialysis 3 times a week for 9 months. Patients were subjected to nutritional assessment at baseline and 3-, 6-, and 9-month follow-up using height Z-score, hand grip strength (HGS) for muscle power assessment, body composition monitor (BCM) for assessing lean tissue mass (LTM) and adipose tissue mass (ATM), and biochemical measures including serum albumin, serum triglyceride, and serum cholesterol.

RESULTS

When comparing baseline and 9-month follow-up values, significant improvement was recorded in height Z-score, LTM, and serum albumin in the intervention group unlike the control group where no significant changes were recorded.

CONCLUSION

IDPN is proposed to be an effective method for preventing and treating malnutrition in children with CKD 5. However, further multi-centric studies with larger sample size and longer duration of follow-up are still recommended.

Associations between cachexia and metalloproteinases, haemodynamics and mortality in heart failure

BACKGROUND

Addressing cachexia in chronic heart failure (CHF) patients is an urgent issue in Japan, the most aged country in the world. We investigated the possible relationships between cachexia and, metalloproteinases and haemodynamics assessed by the cardiac catheterization. We also clarified the prognostic value of cardiac cachexia in the Japanese CHF population.

METHODS AND RESULTS

A total of 370 participants (median age, 69 years; 35% women) were included. The haemodynamic effects of cachexia were analysed by right heart catheterization. The serum levels of matrix metalloproteinase (MMP) and tissue inhibitors of MMP (TIMP), as myocardial collagen turnover markers, were also assessed. Cachexia was present in 88 patients (31%). Overall, 59 patients (16%) had all-cause death. Serum MMP-2 and TIMP-2 levels were higher in cachectic patients than in noncachectic patients (797.5 [649.0-1066.8] vs 610.0 [461.8-756.8] ng/mL; P = .004 and 39.0 [28.0-49.0] vs 24.0 [19.0-37.0] ng/mL; P = .008, respectively). Cachectic patients had greater values of pulmonary vascular resistance (PVR) (161.9 [119.4-225.4] vs 127.8 [90.7-164.8] dynes/sec/cm^-5 , P = .020). Kaplan-Meier survival analysis demonstrated higher probabilities of all-cause death in the cachexia group (log-rank P = .010). Cox proportional hazards modelling showed cachexia was an independent predictor of mortality (hazard ratio, 1.89; 95% confidence interval, 1.06-3.37; P = .029). The random forest model showed that C-reactive protein, age, haemoglobin, PVR and MMP-2 were predictors of cardiac cachexia.

CONCLUSIONS

Cachexia, applying the globally accepted definition, was associated with adverse outcomes in the Japanese CHF population and accompanied by increased activity of MMP species and PVR.

Targeting the Activin Receptor Signaling to Counteract the Multi-Systemic Complications of Cancer and Its Treatments

Muscle wasting, i.e., cachexia, frequently occurs in cancer and associates with poor prognosis and increased morbidity and mortality. Anticancer treatments have also been shown to contribute to sustainment or exacerbation of cachexia, thus affecting quality of life and overall survival in cancer patients. Pre-clinical studies have shown that blocking activin receptor type 2 (ACVR2) or its ligands and their downstream signaling can preserve muscle mass in rodents bearing experimental cancers, as well as in chemotherapy-treated animals. In tumor-bearing mice, the prevention of skeletal and respiratory muscle wasting was also associated with improved survival. However, the definitive proof that improved survival directly results from muscle preservation following blockade of ACVR2 signaling is still lacking, especially considering that concurrent beneficial effects in organs other than skeletal muscle have also been described in the presence of cancer or following chemotherapy treatments paired with counteraction of ACVR2 signaling. Hence, here, we aim to provide an up-to-date literature review on the multifaceted anti-cachectic effects of ACVR2 blockade in preclinical models of cancer, as well as in combination with anticancer treatments.

Nurses' Knowledge in Relation to the Anorexia-Cachexia Syndrome in Cancer Patients: A Cross-National Comparison in Two European Countries

INTRODUCTION

The Anorexia-Cachexia Syndrome (ACS) is a severe complication of cancer and is considered to be a significant cause of morbidity and mortality affecting up to two-thirds of cancer patients and one that needs specialized nursing care. Studies showed that the ACS has been relatively under-researched and under-resourced whist the nurses' knowledge has not been systematically explored.

OBJECTIVE

Τo explores nurses' knowledge, understanding, and management of ACS in clinical practice in two European countries.

METHODS

Descriptive-comparative study with 197 cancer nurses recruited during two National Conferences in Greece and Cyprus. Data were retrieved with the "Investigation of anorexia-cachexia syndrome in Practice" questionnaire.

RESULTS

In terms of nurses' perceptions on ACS, the prevailing characteristic reported in both countries was anorexia (p = .65) followed by weight loss (p = .04). 189 nurses (95.9%, p = .176) do not currently use a tool to assess patients' nutritional status as part of their standard clinical practice. Statistically significant differences were found in relation to the routine assessment of nutritional-related symptoms including early satiety (Cyprus 64% vs. Greece 37%, p = .001), hiccough (66% vs. 36%, p < .001), alteration of the taste/odor sensation (77% vs. 45%, p < .001), problems in the oral cavity (84% vs. 68%, p = .032) and daily activities (85% vs. 69%, p = .032). The priority level for the ACS management differed significantly in the two countries (p = .006), with higher priority being reported in Cyprus.

CONCLUSION

The study showed that more education is needed for cancer nurses to better understand the ACS which can facilitate the better management of the syndrome in clinical practice.

Ehrlich ascites carcinoma as model for studying the cardiac protective effects of curcumin nanoparticles against cardiac damage in female mice

While clinical innovation has improved, cancer or malignant growth stays a genuine medical issue and has been perceived as a significant factor in mortality and morbidity. Current work aimed to define the cardiac defensive effects of curcumin nanoparticles (Cur Nps) against EAC induced cardiac toxicity, injury, and alterations in apoptosis, proliferation, and cytokines immunoreactivity. Forty female mice were aimlessly and equally divided into four groups [Gp1, Control; Gp2, Cur NPs; Gp3, Ehrlich ascites carcinoma (EAC); Gp4, Co-treatment of EAC with Cur NPs (Cur NPs + EAC)]. Serum lactate dehydrogenase (LDH), phosphocreatine kinase (CPK), creatine kinase myoglobin (CK-MB), alkaline phosphatase (ALP), glutamic oxaloacetic transaminase (GOT), cholesterol, triglycerides, potassium ions, cardiac injury, P53, vascular endothelial growth factor protein (VEGF), Bax, and tumor necrosis factor alpha (TNFα) expressions were significantly elevated while sodium ions levels were significantly depleted in EAC when compared to control. Co-treatment of EAC with Cur NPs (Cur NPs + EAC) improved these parameters as compared with EAC group. So, our results indicate that; Cur NPs induced protection to the blood and heart tissue during Ehrlich ascites carcinoma.

The Paradoxical Effect of PARP Inhibitor BGP-15 on Irinotecan-Induced Cachexia and Skeletal Muscle Dysfunction

Simple Summary

Both cancer and the chemotherapy used to treat it are drivers of cachexia, a life-threatening body-wasting condition which complicates cancer treatment. Poly-(ADP-ribose) polymerase (PARP) inhibitors are currently being investigated as a treatment against cancer. Here, we present paradoxical evidence that they might also be useful for mitigating the skeletal muscle specific side-effects of anti-cancer chemotherapy or exacerbate them. BGP-15 is a small molecule PARP inhibitor which protected against irinotecan (IRI)-induced cachexia and loss of skeletal muscle mass and dysfunction in our study. However, peculiarly, BGP-15 adjuvant therapy reduced protein synthesis rates and the expression of key cytoskeletal proteins associated with the dystrophin-associated protein complex and increased matrix metalloproteinase activity, while it increased the propensity for fast-twitch muscles to tear during fatiguing contraction. Our data suggest that both IRI and BGP-15 cause structural remodeling involving proteins associated with the contractile apparatus, cytoskeleton and/or the extracellular matrix which may be only transient and ultimately beneficial or may paradoxically onset a muscular dystrophy phenotype and be detrimental if more permanent.

Abstract

Chemotherapy-induced muscle wasting and dysfunction is a contributing factor to cachexia alongside cancer and increases the risk of morbidity and mortality. Here, we investigate the effects of the chemotherapeutic agent irinotecan (IRI) on skeletal muscle mass and function and whether BGP-15 (a poly-(ADP-ribose) polymerase-1 (PARP-1) inhibitor and heat shock protein co-inducer) adjuvant therapy could protect against IRI-induced skeletal myopathy. Healthy 6-week-old male Balb/C mice (n = 24; 8/group) were treated with six intraperitoneal injections of either vehicle, IRI (30 mg/kg) or BGP-15 adjuvant therapy (IRI+BGP; 15 mg/kg) over two weeks. IRI reduced lean and tibialis anterior mass, which were attenuated by IRI+BGP treatment. Remarkably, IRI reduced muscle protein synthesis, while IRI+BGP reduced protein synthesis further. These changes occurred in the absence of a change in crude markers of mammalian/mechanistic target of rapamycin (mTOR) Complex 1 (mTORC1) signaling and protein degradation. Interestingly, the cytoskeletal protein dystrophin was reduced in both IRI- and IRI+BGP-treated mice, while IRI+BGP treatment also decreased β-dystroglycan, suggesting significant remodeling of the cytoskeleton. IRI reduced absolute force production of the soleus and extensor digitorum longus (EDL) muscles, while IRI+BGP rescued absolute force production of the soleus and strongly trended to rescue force output of the EDL (p = 0.06), which was associated with improvements in mass. During the fatiguing stimulation, IRI+BGP-treated EDL muscles were somewhat susceptible to rupture at the musculotendinous junction, likely due to BGP-15’s capacity to maintain the rate of force development within a weakened environment characterized by significant structural remodeling. Our paradoxical data highlight that BGP-15 has some therapeutic advantage by attenuating IRI-induced skeletal myopathy; however, its effects on the remodeling of the cytoskeleton and extracellular matrix, which appear to make fast-twitch muscles more prone to tearing during contraction, could suggest the induction of muscular dystrophy and, thus, require further characterization.

The Etiology and Impact of Muscle Wasting in Metastatic Cancer

Metastasis arises when cancer cells disseminate from their site of origin and invade distant organs. While cancer cells rarely colonize muscle, they often induce a debilitating muscle-wasting condition known as cachexia that compromises feeding, breathing, and cardiac function in metastatic cancer patients. In fact, nearly 80% of metastatic cancer patients experience a spectrum of muscle-wasting states, which deteriorates the quality of life and overall survival of cancer patients. Muscle wasting in cancer results from increased muscle catabolism induced by circulating tumor factors and a systemic metabolic dysfunction. In addition, muscle loss can be exacerbated by the exposure to antineoplastic therapies and the process of aging. With no approved therapies to alleviate cachexia, muscle health, therefore, becomes a key determinant of prognosis, treatment response, and survival in metastatic cancer patients. This review will discuss the current understanding of cancer-associated cachexia and highlight promising therapeutic strategies to treat muscle wasting in the context of metastatic cancers.

T. gondii infection induces IL-1R dependent chronic cachexia and perivascular fibrosis in the liver and skeletal muscle

Cachexia is a progressive muscle wasting disease that contributes to death in a wide range of chronic diseases. Currently, the cachexia field lacks animal models that recapitulate the long-term kinetics of clinical disease, which would provide insight into the pathophysiology of chronic cachexia and a tool to test therapeutics for disease reversal. Toxoplasma gondii (T. gondii) is a protozoan parasite that uses conserved mechanisms to infect rodents and human hosts. Infection is lifelong and has been associated with chronic weight loss and muscle atrophy in mice. We have recently shown that T. gondii-induced muscle atrophy meets the clinical definition of cachexia. Here, the longevity of the T. gondii-induced chronic cachexia model revealed that cachectic mice develop perivascular fibrosis in major metabolic organs, including the adipose tissue, skeletal muscle, and liver by 9 weeks post-infection. Development of cachexia, as well as liver and skeletal muscle fibrosis, is dependent on intact signaling through the type I IL-1R receptor. IL-1α is sufficient to activate cultured fibroblasts and primary hepatic stellate cells (myofibroblast precursors in the liver) in vitro, and IL-1α is elevated in the sera and liver of cachectic, suggesting a mechanism by which chronic IL-1R signaling could be leading to cachexia-associated fibrosis.

Ketone Body, 3-Hydroxybutyrate: Minor Metabolite - Major Medical Manifestations

Ketone bodies - 3-hydroxybutyrate (3-OHB), acetoacetate, and acetone - are ancient, evolutionarily preserved, small fuel substrates, which uniquely can substitute and alternate with glucose under conditions of fuel and food deficiency. Once canonized as a noxious, toxic pathogen leading to ketoacidosis in patients with diabetes, it is now becoming increasingly clear that 3-OHB possesses a large number of beneficial, life-preserving effects in the fields of clinical science and medicine. 3-OHB, the most prominent ketone body, binds to specific hydroxyl-carboxylic acid receptors and inhibits histone deacetylase enzymes, free fatty acid receptors, and the NOD-like receptor protein 3 inflammasome, tentatively inhibiting lipolysis, inflammation, oxidative stress, cancer growth, angiogenesis, and atherosclerosis, and perhaps contributing to the increased longevity associated with exercise and caloric restriction. Clinically ketone bodies/ketogenic diets have for a long time been used to reduce the incidence of seizures in epilepsy and may have a role in the treatment of other neurological diseases such as dementia. 3-OHB also acts to preserve muscle protein during systemic inflammation and is an important component of the metabolic defense against insulin-induced hypoglycemia. Most recently, a number of studies have reported that 3-OHB dramatically increases myocardial blood flow and cardiac output in control subjects and patients with heart failure. At the moment, scientific interest in ketone bodies, in particular 3-OHB, is in a hectic transit and, hopefully, future, much needed, controlled clinical studies will reveal and determine to which extent the diverse biological manifestations of 3-OHB should be introduced medically.

A review of pathological findings in impalas (Aepyceros melampus) in South Africa

Impalas (Aepyceros melampus) are common African antelope. A retrospective study was conducted of 251 impala cases from game farms, national parks and zoos submitted by veterinarians and pathologists in South Africa (2003-2016). Histopathology slides as well as records of macroscopic lesions and additional diagnostic tests performed were examined. Non-infectious conditions, such as acute pulmonary congestion and oedema, cachexia, traumatic injury and anaesthetic-related mortality were the most common causes of morbidity and mortality. Bacterial sepsis was the most common infectious disease, whilst skeletal muscle and myocardial sarcocystosis and verminous cholangitis and pneumonia were the most common parasitic diseases. Although the retrospective nature of this study limits the significance of the relative prevalence of lesions in the three locations, management decisions and diagnostic plans may be informed by the results. Impala from game farms had significantly more cachexia cases than those from other locations. Impala from zoos had significantly more lymphoid depletion than those from other locations. These findings suggest that nutrition and pasture management, enclosure design, management of intra- and interspecies aggression and improved anaesthetic protocols could improve animal welfare and survival of impala on game farms and in zoos. This report presents a detailed survey of diseases and conditions found in impala that provides baseline data for veterinary pathologists.

Reduced LDL-Cholesterol and Reduced Total Cholesterol as Potential Indicators of Early Cancer in Male Treatment-Naïve Cancer Patients With Pre-cachexia and Cachexia

Cancer cachexia is characterized by the impairment of glucose and lipid homeostasis, the acceleration of processes promoting the mobilization of energy-rich compounds (e.g., insulin resistance, gluconeogenesis, and lipolysis) and the simultaneous activation of highly energy-demanding processes (e.g., systemic inflammation and activation of brown adipose tissue). We hypothesized that these processes might themselves change during cancer cachexia progression, such that plasma levels of glucose and lipids might be used to distinguish between the non-malignant state, pre-cachexia and cachexia. We performed an initial cross-sectional study including 60 treatment naïve cancer patients (38 with cancer cachexia and 22 with cancer pre-cachexia) and 61 patients without malignancy (21 with metabolic syndrome and 40 controls). Differences in lipids (total cholesterol, LDL and HDL cholesterol) and plasma fasting glucose were analyzed across various group configurations, with adjustments to age and antidiabetic or lipid-lowering drugs. Our study showed that levels of LDL cholesterol and total cholesterol might indicate cachexia stages irrespective of the presence of metabolic syndrome or lipid-lowering medication. High levels of plasma glucose were only seen in cachectic cancer patients on antidiabetics. These observations indicate that markers of metabolic dysregulation associated with cachexia progression might be exploited for early detection of malignancy.

Understanding cachexia in the context of metastatic progression

Tumours reprogram host physiology, metabolism and immune responses during cancer progression. The release of soluble factors, exosomes and metabolites from tumours leads to systemic changes in distant organs, where cancer cells metastasize and grow. These tumour-derived circulating factors also profoundly impact tissues that are rarely inhabited by metastatic cancer cells such as skeletal muscle and adipose tissue. In fact, the majority of patients with metastatic cancer develop a debilitating muscle-wasting syndrome, known as cachexia, that is associated with decreased tolerance to antineoplastic therapy, poor prognosis and accelerated death, with no approved treatments. In this Perspective, we discuss the development of cachexia in the context of metastatic progression. We briefly discuss how circulating factors either directly or indirectly promote cachexia development and examine how signals from the metastatic process can trigger and amplify this process. Finally, we highlight promising therapeutic opportunities for targeting cachexia in the context of metastatic cancers.

Evaluation of the Cardiac Protection Conferred by Proanthocyanidins in Grape Seeds against Development of Ehrlich Solid Tumors in Mice

Examination of the antineoplastic effects of a range of chemical compounds is often undertaken via the transplantable tumor model of Ehrlich solid tumor (EST), which is a simulation of breast cancer. The purpose of this study was to explore how cardiac toxicity, damage, oxidative stress, and changes in the expressions of TNFα and apoptotic P53 triggered by EST could be countered with grape seed proanthocyanidins (GSPE). To that end, 50 female mice were used, with arbitrary and equal distribution into five groups, namely, the control group (G1), GSPE group (G2), EST group (G3), GSPE + EST (G4; cotreatment consisted of mice that received GSPE treatment at the beginning of EST induction over a period of 14 days), and EST + GSPE (G5; posttreatment consisted of mice with EST that received GSPE treatment for 14 days following the 14 days since the induction of EST). By comparison with the control group, the EST group had significantly higher levels of serum lactate dehydrogenase (LDH), creatine phosphokinase (CPK), creatine kinase MB (CK-MB), myoglobin, cardiac TBARS, nitric oxide (NO), total thiol and hydrogen peroxide, cardiac damage, and expression of P53 and TNFα. On the other hand, the EST group had significantly lower levels of cardiac catalase and total antioxidant (TAC) than the control group. Furthermore, better improvement in cardiac toxicity, oxidative stress, damage, apoptosis, and TNFα expressions was displayed by the cotreated (GSPE + EST) group than by the posttreated (EST + GSPE) group. This led to the conclusion that GSPE conferred cardiac protective and antioxidant effects against EST. This finding calls for more investigation on the benefits of grape seeds as adjuvant agents to prevent and treat cardiac toxicity.

Is Neuronal Histamine Signaling Involved in Cancer Cachexia? Implications and Perspectives

In this paper, we present evidence in support of our hypothesis that the neuronal histaminergic system might be involved in cancer cachexia¹. To build our premise, we present the research and the reasonable inferences that can be drawn from it in a section by section approach starting from one of the key issues related to cachexia, increased resting energy expenditure (REE), and progressing to the other, anorexia. Based on an extensive survey of the literature and our own deliberations on the abovementioned topics, we investigate whether histamine signaling might be the mechanism used by a tumor to hijack the body's thermogenic machinery. Our hypothesis in short is that hypothalamic histaminergic neurons are stimulated by inputs from the parasympathetic nervous system (PSNS), which senses tumor traits early in cancer development. Histamine release in the preoptic area of the hypothalamus primarily activates brown adipose tissue (BAT), triggering a highly energy demanding mechanism. Chronic activation of BAT, which, in this context, refers to intermittent and/or low grade activation by the sympathetic nervous system, leads to browning of white adipose tissue and further enhances thermogenic potential. Aberrant histamine signaling not only triggers energy-consuming processes, but also anorexia. Moreover, since functions such as taste, smell, and sleep are governed by discrete structures of the brain, which are targeted by distinct histaminergic neuron populations even relatively minor symptoms of cachexia, such as sleep disturbances and taste and smell distortions, also might be ascribed to aberrant histamine signaling. In late stage cachexia, the sympathetic tone in skeletal muscle breaks down, which we hypothesize might be caused by a reduction in histamine signaling or by the interference of other cachexia related mechanisms. Histamine signaling thus might delineate distinct stages of cachexia progression, with the early phase marked by a PSNS-mediated increase in histamine signaling, increased sympathetic tone and symptomatic adipose tissue depletion, and the late phase characterized by reduced histamine signaling, decreased sympathetic tone and symptomatic muscle wasting. To support our hypothesis, we review the literature from across disciplines and highlight the many commonalities between the mechanisms underlying cancer cachexia and current research findings on the regulation of energy homeostasis (particularly as it relates to hypothalamic histamine signaling). Extrapolating from the current body of knowledge, we develop our hypothetical framework (based on experimentally falsifiable assumptions) about the role of a distinct neuron population in the pathophysiology of cancer cachexia. Our hope is that presenting our ideas will spark discussion about the pathophysiology of cachexia, cancer's devastating and intractable syndrome.

The Microbiota and Cancer Cachexia

Cancer cachexia is a multifactorial syndrome defined by weight loss, muscle wasting, and systemic inflammation. It affects the majority of patients with advanced cancer and is associated with poor treatment response, early mortality and decreased quality of life. The microbiota has been implicated in cancer cachexia through pathways of systemic inflammation, gut barrier dysfunction and muscle wasting. The imbalance of the microbiota, known as dysbiosis, has been shown to influence cancer cachexia. Bacteria that play beneficial and detrimental roles in the disease pathogenesis have been identified. The phenotype of cancer cachexia is associated with decreased levels of Lactobacillales and increased levels of Enterobacteriaceae and Parabacteroides. Currently, there are no treatment options that demonstrate increased survival or the quality of life in patients suffering from cancer cachexia. Through the manipulation of beneficial bacteria in the gut microbiota, different treatment options have been explored. Prebiotics and probiotics have been shown to improve outcomes in animal models of cachexia. Expounding on this mechanism, fecal microbiota transplant (FMT) holds promise for a future treatment of cancer cachexia. Further research is necessary to address this detrimental disease process and improve the lives of patients suffering from cancer cachexia.

ER Stress and Unfolded Protein Response in Cancer Cachexia

Cancer cachexia is a devastating syndrome characterized by unintentional weight loss attributed to extensive skeletal muscle wasting. The pathogenesis of cachexia is multifactorial because of complex interactions of tumor and host factors. The irreversible wasting syndrome has been ascribed to systemic inflammation, insulin resistance, dysfunctional mitochondria, oxidative stress, and heightened activation of ubiquitin-proteasome system and macroautophagy. Accumulating evidence suggests that deviant regulation of an array of signaling pathways engenders cancer cachexia where the human body is sustained in an incessant self-consuming catabolic state. Recent studies have further suggested that several components of endoplasmic reticulum (ER) stress-induced unfolded protein response (UPR) are activated in skeletal muscle of animal models and muscle biopsies of cachectic cancer patients. However, the exact role of ER stress and the individual arms of the UPR in the regulation of skeletal muscle mass in various catabolic states including cancer has just begun to be elucidated. This review provides a succinct overview of emerging roles of ER stress and the UPR in cancer-induced skeletal muscle wasting.

Awareness, Understanding and Treatment Practices when Managing Cachexia in End-Stage Kidney Disease

BACKGROUND

Cachexia is a wasting syndrome found within a range of chronic illnesses/life-limiting conditions, however awareness and understanding of cachexia amongst renal Health Care Professionals has not been investigated.

OBJECTIVES

To ascertain the awareness, understanding and treatment practices of Health Care Professionals who provide care for people with cachexia and end-stage renal disease.

METHODS

Health Care Professionals were recruited via the European Dialysis and Transplant Nurses Association/European Renal Care Association in September 2018. This was an exploratory study using a mixed-methods approach with those who provide care for patients with end-stage renal disease and cachexia. An online survey and two focus groups were conducted. Descriptive statistics and inductive thematic analysis were used to explore current knowledge and practices in renal cachexia.

RESULTS

A total of 93 participants from 30 countries completed the online survey. Twelve Health Care Professionals agreed to participate in the focus groups. Reduced appetite, weight loss and muscle loss in relation to cachexia were accurately described, but the percentage of weight loss was unknown. The importance of multi-professional collaboration was recognised, however, the current management of cachexia was wide-ranging. Quality of life, patient-clinician communication and specialist support for carers were regarded as vital.

CONCLUSION

Timely identification and management of cachexia are needed to improve the quality of life for patients and appropriately support families. In order for these goals to be achieved, there is a need to increase awareness and understanding of cachexia amongst renal nurses.

Muscle wasting in patients with end-stage renal disease or early-stage lung cancer: common mechanisms at work

BACKGROUND

Loss of muscle mass worsens many diseases such as cancer and renal failure, contributes to the frailty syndrome, and is associated with an increased risk of death. Studies conducted on animal models have revealed the preponderant role of muscle proteolysis and in particular the activation of the ubiquitin proteasome system (UPS). Studies conducted in humans remain scarce, especially within renal deficiency. Whether a shared atrophying programme exists independently of the nature of the disease remains to be established. The aim of this work was to identify common modifications at the transcriptomic level or the proteomic level in atrophying skeletal muscles from cancer and renal failure patients.

METHODS

Muscle biopsies were performed during scheduled interventions in early-stage (no treatment and no detectable muscle loss) lung cancer (LC), chronic haemodialysis (HD), or healthy (CT) patients (n = 7 per group; 86% male; 69.6 ± 11.4, 67.9 ± 8.6, and 70.2 ± 7.9 years P > 0.9 for the CT, LC, and HD groups, respectively). Gene expression of members of the UPS, autophagy, and apoptotic systems was measured by quantitative real-time PCR. A global analysis of the soluble muscle proteome was conducted by shotgun proteomics for investigating the processes altered.

RESULTS

We found an increased expression of several UPS and autophagy-related enzymes in both LC and HD patients. The E3 ligases MuRF1 (+56 to 78%, P < 0.01), MAFbx (+68 to 84%, P = 0.02), Hdm2 (+37 to 59%, P = 0.02), and MUSA1/Fbxo30 (+47 to 106%, P = 0.01) and the autophagy-related genes CTPL (+33 to 47%, P = 0.03) and SQSTM1 (+47 to 137%, P < 0.01) were overexpressed. Mass spectrometry identified >1700 proteins, and principal component analysis revealed three differential proteomes that matched to the three groups of patients. Orthogonal partial least square discriminant analysis created a model, which distinguished the muscles of diseased patients (LC or HD) from those of CT subjects. Proteins that most contributed to the model were selected. Functional analysis revealed up to 238 proteins belonging to nine metabolic processes (inflammatory response, proteolysis, cytoskeleton organization, glucose metabolism, muscle contraction, oxidant detoxification, energy metabolism, fatty acid metabolism, and extracellular matrix) involved in and/or altered by the atrophying programme in both LC and HD patients. This was confirmed by a co-expression network analysis.

CONCLUSIONS

We were able to identify highly similar modifications of several metabolic pathways in patients exhibiting diseases with different aetiologies (early-stage LC vs. long-term renal failure). This strongly suggests that a common atrophying programme exists independently of the disease in human.

Exercise-Induced Myokines With Therapeutic Potential for Muscle Wasting

Skeletal muscle is a highly vascularized tissue that can secrete proteins called myokines. These muscle-secreted factors exert biological functions in muscle itself (autocrine effect) or on short- or long-distant organs (paracrine/endocrine effects) and control processes such as metabolism, angiogenesis, or inflammation. Widely differing diseases ranging from genetic myopathies to cancers are emerging as causing dysregulated secretion of myokines from skeletal muscles. Myokines are also involved in the control of muscle size and may be important to be restored to normal levels to alleviate muscle wasting in various conditions, such as cancer, untreated diabetes, chronic obstructive pulmonary disease, aging, or heart failure. Interestingly, many myokines are induced by exercise (muscle-derived exerkines) and some even by specific types of physical activity, but more studies are needed on this issue. Most exercise-induced myokines travel throughout the body by means of extracellular vesicles. Restoring myokines by physical activity may be added to the list of mechanisms by which exercise exerts preventative or curative effects against a large number of diseases, including the deleterious muscle wasting they may cause. Extending our understanding about which myokines could be usefully restored in certain diseases might help in prescribing more tailored exercise or myokine-based drugs.

Metabolic Profiling of Tumors, Sera, and Skeletal Muscles from an Orthotopic Murine Model of Gastric Cancer Associated-Cachexia

Cachexia is a complex metabolic derangement syndrome that affects approximately 50-80% of cancer patients. So far, few works have been reported to provide a global overview of gastric cancer cachexia (GCC)-related metabolic changes. We established a GCC murine model by orthotopicly implanting BGC823 cell line and conducted NMR-based metabolomic analysis of gastric tissues, sera, and gastrocnemius. The model with typical cachexia symptoms, confirmed by significant weight loss and muscle atrophy, showed distinctly distinguished metabolic profiles of tumors, sera, and gastrocnemius from sham mice. We identified 20 differential metabolites in tumors, 13 in sera, and 14 in gastrocnemius. Tumor extracts displayed increased pyruvate and lactate, and decreased hypoxanthine, inosine, and inosinate, indicating significantly altered glucose and nucleic acid metabolisms. Cachectic mice exhibited up-regulated serum lactate and glycerol, and down-regulated glucose, which were closely related to hyperlipidemia and hypoglycemia. Furthermore, gastrocnemius transcriptomic and metabolomic data revealed that GCC induced perturbed pathways mainly concentrated on carbohydrate and amino acid metabolism. Specifically, cachectic gastrocnemius exhibited increased α-ketoglutarate and decreased glucose. In vitro study indicated that α-ketoglutarate could prompt myoblasts proliferation and reduce glucose deficiency-induced myotubes atrophy. Overall, this work provides a global metabolic overview to understand the metabolic alterations associated with GCC-induced muscle atrophy.

Hyponatremia in the Dialysis Population

Sodium derangements are among the most frequently encountered electrolyte disorders in patients with end-stage renal disease. As dialysis patients are predisposed to hyponatremia via multiple pathways, assessment of extracellular volume status is an essential first step in disentangling potential etiologic factors. In addition, multiple large population-based studies indicate that proxies of malnutrition (e.g., low body mass index, serum albumin, and serum creatinine levels) and loss of residual kidney function are important determinants of hyponatremia in dialysis patients. Among hemodialysis and peritoneal dialysis patients, evidence suggests that incrementally lower sodium levels are associated with increasingly higher death risk, highlighting the long-term risk of hyponatremia. Whereas in conventional survival models incrementally lower serum sodium concentrations are associated with worse mortality in hemodialysis patients, studies that have examined repeated measures of predialysis sodium have demonstrated mixed associations of time-varying sodium with higher mortality risk (i.e., U-shaped vs. inverse linear relationships). Although the causality of the hyponatremia-mortality association in dialysis patients remains uncertain, there are several plausible pathways by which lower sodium levels may lead to higher death risk, including central nervous system toxicity, falls and fractures, infection-related complications, and impaired cardiac function. Areas of uncertainty ripe for future studies include the following: (i) mechanistic pathways by which lower serum sodium levels are linked with higher mortality in dialysis patients, (ii) whether correction of sodium derangements improves outcomes, (iii) the optimal sodium target, and (iv) the impact of age and other sociodemographic factors on hyponatremia-outcome associations.

Orphan disease status of cancer cachexia in the USA and in the European Union: a systematic review

BACKGROUND

Cachexia has significant impact on the patients' quality of life and prognosis. It is frequently observed in patients with cancer, especially in advanced stages, but prevalence data for the overall population are lacking. Good quality estimates of cancer cachexia in general and for each of the major cancer types would be highly relevant for potential treatment development efforts in this field. Both the USA and European Union (EU) have implemented special clinical development rules for such rare disorders what are called 'orphan diseases'. The cut-off level for a disease to be considered an orphan disease in the USA is 200 000 people (0.06% of the population) and EU is 5 per 10 000 people (0.05% of the population).

METHODS

For this systematic review, we searched at PubMed (from inception to 31 January 2018) to identify clinical studies that assessed the prevalence of cachexia in cancer patients at risk. Studies reporting the prevalence of either cancer cachexia or wasting disease in the top-10 cancer types and 4 other selected cancer types known to be particularly commonly complicated by cachexia were included in this analysis (i.e. prostate cancer, breast cancer, colorectal cancer, melanoma, endometrial cancer, thyroid cancer, urinary bladder cancer, non-hodgkin lymphoma, lung cancer, kidney and renal pelvis cancer, head and neck cancer, gastric cancer, liver cancer, and pancreatic cancer). We calculated the current burden of cancer cachexia, disease by disease, in the USA and in the EU and compared them to the current guidelines for the definition of orphan disease status.

RESULTS

We estimate that in 2014 in the USA, a total of 527 100 patients (16.5 subjects per 10 000 people of the total population), and in 2013 in the EU, a total of 800 300 patients (15.8 subjects per 10 000 people of the total population) suffered from cancer cachexia (of any kind). In the 14 separately analysed cancer types, the prevalence of cancer cachexia in the USA ranged between 11 300 (0.4/10 000, gastric cancer) and 92 000 patients (2.9/10 000, lung cancer) and in the EU between 14 300 (0.3/10 000, melanoma of the skin) and 150 100 (3.0/10 000, colorectal cancer).

CONCLUSIONS

The absolute number of patients affected by cancer cachexia in each cancer group is lower than the defined thresholds for orphan diseases in the USA and EU. Cancer cachexia in each subgroup separately should be considered an orphan disease.

Assessing Metabolic Dysregulation in Muscle During Cachexia

Cancer cachexia is a metabolic disease characterized by a negative energy balance associated with systemic weight loss and poor quality of life.In particular, skeletal muscle, which represents almost 50% of the total body mass, is strongly affected, and metabolic alterations therein (e.g., insulin resistance and mitochondrial dysfunction) can eventually support tumor growth by facilitating nutrient scavenging by the growing mass. Interestingly, metabolic interventions on wasting muscle have been proven to be protective, advocating for the importance of metabolic regulation in the wasting muscle.Here, we will briefly define the current knowledge of metabolic regulation in cachexia and provide a protocol to grow and differentiate in vitro myotubes for the assessment of mitochondrial metabolism during cachexia.

Muscle wasting diseases has two distinct trajectories on the 3-dimensional age-BMI-peak VO2 scatterplot

Abstract Background: Frailty and sarcopenia are age-related morbid states, and a low body mass index (BMI) is a characteristic of frailty and cachexia. However, no common index for assessing these three muscle wasting states is available, making it difficult to understand the relationship among them. Peak oxygen uptake (peak VO2), an index of life expectancy, may be a useful common index. Therefore, this study aimed to investigate the relationship among sarcopenia, frailty, and cachexia using age, BMI, and peak VO2. Methods: Participants were 175 Japanese community dwelling older adults (58 men, 117 women; 77.6 years). We assessed biochemical, physiological, and physical factors, and symptoms associated with frailty, and cachexia. Peak VO2 was assessed with a cardiopulmonary exercise test. Participants were classified into five groups: robust, pre-frail, frail, sarcopenia, and cachexia. We compared the groups by age, BMI, and peakVO2 with average values and 95% confidence intervals (CIs).Results: 17% (n=30) of participants were classified as robust, 40% (n=70) as pre-frail, 12% (n=21) as sarcopenia, 25% (n=44) as frail, and 6% (n=10) as cachexia. Significant differences were found in age (robust vs. frail, pre-frail vs. frail), BMI (robust vs. cachexia, pre-frail vs. cachexia, frail vs. cachexia), and peak VO2 (robust vs. frail, robust vs. cachexia, pre-frail vs. cachexia) with average values and 95% CIs. Three dimensions among age, BMI and peak VO2 revealed two trajectories (from robust to frailty via pre-frailty, and from robust to cachexia via sarcopenia) among muscle wasting diseases.Conclusions: This study revealed two trajectories among muscle wasting diseases.