Complement system in nutritional deficiency

The immune system in children with malnutrition--a systematic review

Background

Malnourished children have increased risk of dying, with most deaths caused by infectious diseases. One mechanism behind this may be impaired immune function. However, this immune deficiency of malnutrition has not previously been systematically reviewed.

Objectives

To review the scientific literature about immune function in children with malnutrition.

Methods

A systematic literature search was done in PubMed, and additional articles identified in reference lists and by correspondence with experts in the field. The inclusion criteria were studies investigating immune parameters in children aged 1–60 months, in relation to malnutrition, defined as wasting, underweight, stunting, or oedematous malnutrition.

Results

The literature search yielded 3402 articles, of which 245 met the inclusion criteria. Most were published between 1970 and 1990, and only 33 after 2003. Malnutrition is associated with impaired gut-barrier function, reduced exocrine secretion of protective substances, and low levels of plasma complement. Lymphatic tissue, particularly the thymus, undergoes atrophy, and delayed-type hypersensitivity responses are reduced. Levels of antibodies produced after vaccination are reduced in severely malnourished children, but intact in moderate malnutrition. Cytokine patterns are skewed towards a Th2-response. Other immune parameters seem intact or elevated: leukocyte and lymphocyte counts are unaffected, and levels of immunoglobulins, particularly immunoglobulin A, are high. The acute phase response appears intact, and sometimes present in the absence of clinical infection. Limitations to the studies include their observational and often cross-sectional design and frequent confounding by infections in the children studied.

Conclusion

The immunological alterations associated with malnutrition in children may contribute to increased mortality. However, the underlying mechanisms are still inadequately understood, as well as why different types of malnutrition are associated with different immunological alterations. Better designed prospective studies are needed, based on current understanding of immunology and with state-of-the-art methods.

Physiologic role of the complement system in host defense, disease, and malnutrition

The role of the complement system as a system merging early-phase innate immunity with later-phase acquired immunity has been established. C3 is a key protein of the complement system. It is activated in four pathways: (1) the alternative pathway, (2) the mannan binding protein pathway, (3) the C-reactive protein pathway, and (4) the natural IgM pathway in innate immunity. It is also activated in (1) a classic pathway, i.e., through an antigen-antibody complex, and (2) by injured host cells in acquired immunity. Activation of C3 results in a variety of immunologic reactions such as immune adherence, phagocytosis, antibody response, cytolysis, inflammation, and killing of pathogenic microorganisms. Pathologic pictures of the complement system in various diseases were reviewed. Attention was focused on hypocomplementemia in the malnourished state. In humans and in experimental animals, reduced complement levels, especially of C3, were observed in relation to lowered host defense against infection. Hypocomplementemia improved after nutritional rehabilitation with a concomitant improvement of the clinical picture and recovery of host resistance. Enhancement of C3 levels in malnourished or well-nourished rats resulted in heightened resistance against bacterial infections. On the basis of these experimental and clinical observations, we obtained clues to prevent or treat a compromised host defense system in malnourished states.