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Sturgeon JP, Njunge JM, Bourke CD, Gonzales GB, Robertson RC, Bwakura-Dangarembizi M, Berkley JA, Kelly P, Prendergast AJ. Inflammation: the driver of poor outcomes among children with severe acute malnutrition? Nutr Rev 2023; 81:1636-1652. [PMID: 36977352 PMCID: PMC10639108 DOI: 10.1093/nutrit/nuad030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
Abstract
Severe acute malnutrition (SAM) is the most life-threatening form of undernutrition and underlies at least 10% of all deaths among children younger than 5 years in low-income countries. SAM is a complex, multisystem disease, with physiological perturbations observed in conjunction with the loss of lean mass, including structural and functional changes in many organ systems. Despite the high mortality burden, predominantly due to infections, the underlying pathogenic pathways remain poorly understood. Intestinal and systemic inflammation is heightened in children with SAM. Chronic inflammation and its consequent immunomodulation may explain the increased morbidity and mortality from infections in children with SAM, both during hospitalization and in the longer term after discharge. Recognition of the role of inflammation in SAM is critical in considering new therapeutic targets in this disease, which has not seen a transformational approach to treatment for several decades. This review highlights the central role of inflammation in the wide-ranging pathophysiology of SAM, as well as identifying potential interventions that have biological plausibility based on evidence from other inflammatory syndromes.
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Affiliation(s)
- Jonathan P Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | - James M Njunge
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Claire D Bourke
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Gerard Bryan Gonzales
- Nutrition, Metabolism and Genomics Group, Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, Netherlands
| | - Ruairi C Robertson
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | | | - James A Berkley
- The Childhood Acute Illness & Nutrition Network, Nairobi, Kenya
- KEMRI/Wellcome Trust Research Programme, Kilifi, Kenya
| | - Paul Kelly
- is with the Tropical Gastroenterology and Nutrition Group, University of Zambia, Lusaka, Zambia
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
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Phiri TN, Mutasa K, Rukobo S, Govha M, Mushayanembwa P, Mwakamui S, Haider T, Zyambo K, Dumbura C, Tome J, Runodamoto T, Chidamba L, Majo FD, Ngosa D, Chandwe K, Kapoma C, Mwapenya B, Mufukari W, Sturgeon JP, Robertson RC, Smuk M, Ntozini R, Nathoo K, Amadi B, Kelly P, Bwakura-Dangarembizi M, Prendergast AJ, Bourke CD. Severe acute malnutrition promotes bacterial binding over proinflammatory cytokine secretion by circulating innate immune cells. SCIENCE ADVANCES 2023; 9:eadh2284. [PMID: 37910623 PMCID: PMC10619937 DOI: 10.1126/sciadv.adh2284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 09/29/2023] [Indexed: 11/03/2023]
Abstract
Children with severe acute malnutrition (SAM) have high infectious mortality and morbidity, implicating defects in their immune defenses. We hypothesized that circulating innate immune cells from children (0 to 59 months) hospitalized with SAM in Zambia and Zimbabwe (n = 141) have distinct capacity to respond to bacteria relative to adequately nourished healthy controls (n = 92). SAM inpatients had higher neutrophil and monocyte Escherichia coli binding capacity but lower monocyte activation and proinflammatory mediator secretion in response to lipopolysaccharide or heat-killed Salmonella typhimurium than controls. Among SAM cases, wasting severity was negatively associated with cytokine secretion, children with HIV had lower monocyte activation, and the youngest children released the least myeloperoxidase upon stimulation. Inpatient bacterial binding capacity and monocyte activation were associated with higher odds of persistent SAM at discharge, a risk factor for subsequent mortality. Thus, SAM shifts innate immune cell function, favoring bacterial containment over proinflammatory activation, which may contribute to health deficits after discharge.
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Affiliation(s)
- Tracy N. Phiri
- Tropical Gastroenterology and Nutrition group (TROPGAN), University of Zambia School of Medicine, Lusaka, Zambia
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Sandra Rukobo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Margaret Govha
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | - Simutanyi Mwakamui
- Tropical Gastroenterology and Nutrition group (TROPGAN), University of Zambia School of Medicine, Lusaka, Zambia
| | - Tafhima Haider
- Blizard Institute, Queen Mary University of London, London, UK
| | - Kanekwa Zyambo
- Tropical Gastroenterology and Nutrition group (TROPGAN), University of Zambia School of Medicine, Lusaka, Zambia
| | - Cherlynn Dumbura
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Joice Tome
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | - Leah Chidamba
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Florence D. Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Deophine Ngosa
- Tropical Gastroenterology and Nutrition group (TROPGAN), University of Zambia School of Medicine, Lusaka, Zambia
| | - Kanta Chandwe
- Tropical Gastroenterology and Nutrition group (TROPGAN), University of Zambia School of Medicine, Lusaka, Zambia
| | - Chanda Kapoma
- Tropical Gastroenterology and Nutrition group (TROPGAN), University of Zambia School of Medicine, Lusaka, Zambia
| | - Benjamin Mwapenya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Wadzanai Mufukari
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jonathan P. Sturgeon
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Melanie Smuk
- Blizard Institute, Queen Mary University of London, London, UK
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kusum Nathoo
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Beatrice Amadi
- Tropical Gastroenterology and Nutrition group (TROPGAN), University of Zambia School of Medicine, Lusaka, Zambia
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition group (TROPGAN), University of Zambia School of Medicine, Lusaka, Zambia
- Blizard Institute, Queen Mary University of London, London, UK
| | - Mutsa Bwakura-Dangarembizi
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Department of Paediatrics and Child Health, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Andrew J. Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
| | - Claire D. Bourke
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Blizard Institute, Queen Mary University of London, London, UK
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Mutasa K, Tome J, Rukobo S, Govha M, Mushayanembwa P, Matimba FS, Chiorera CK, Majo FD, Tavengwa NV, Mutasa B, Chasekwa B, Humphrey JH, Ntozini R, Prendergast AJ, Bourke CD. Stunting Status and Exposure to Infection and Inflammation in Early Life Shape Antibacterial Immune Cell Function Among Zimbabwean Children. Front Immunol 2022; 13:899296. [PMID: 35769481 PMCID: PMC9234645 DOI: 10.3389/fimmu.2022.899296] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/11/2022] [Indexed: 11/23/2022] Open
Abstract
Background Children who are stunted (length-for-age Z-score<-2) are at greater risk of infectious morbidity and mortality. Previous studies suggest that stunted children have elevated inflammatory biomarkers, but no studies have characterised their capacity to respond to new infections (i.e., their immune function). We hypothesised that antibacterial immune function would differ between stunted and non-stunted children and relate to their health and environment during early life. Methods We enrolled a cross-sectional cohort of 113 HIV-negative children nested within a longitudinal cluster-randomised controlled trial of household-level infant and young child feeding (IYCF) and water, sanitation and hygiene (WASH) interventions in rural Zimbabwe (SHINE; Clinical trials registration: NCT01824940). Venous blood was collected at 18 months of age and cultured for 24 h without antigen or with bacterial antigens: heat-killed Salmonella typhimurium (HKST) or Escherichia coli lipopolysaccharide (LPS). TNFα, IL-6, IL-8, IL-12p70, hepcidin, soluble (s)CD163, myeloperoxidase (MPO) and IFNβ were quantified in culture supernatants by ELISA to determine antigen-specific immune function. The effect of stunting status and early-life exposures (anthropometry, inflammation at 18 months, maternal health during pregnancy, household WASH) on immune function was tested in logit and censored log-normal (tobit) regression models. Results Children who were stunted (n = 44) had higher proportions (86.4% vs. 65.2%; 88.6% vs. 73.4%) and concentrations of LPS-specific IL-6 (geometric mean difference (95% CI): 3.46 pg/mL (1.09, 10.80), p = 0.035) and IL-8 (3.52 pg/mL (1.20, 10.38), p = 0.022) than non-stunted children (n = 69). Bacterial antigen-specific pro-inflammatory cytokine concentrations were associated with biomarkers of child enteropathy at 18 months and biomarkers of systemic inflammation and enteropathy in their mothers during pregnancy. Children exposed to the WASH intervention (n = 33) produced higher LPS- (GMD (95% CI): 10.48 pg/mL (1.84, 60.31), p = 0.008) and HKST-specific MPO (5.10 pg/mL (1.77, 14.88), p = 0.003) than children in the no WASH group (n = 80). There was no difference in antigen-specific immune function between the IYCF (n = 55) and no IYCF groups (n = 58). Conclusions Antibacterial immune function among 18-month-old children in a low-income setting was shaped by their stunting status and prior exposure to maternal inflammation and household WASH. Heterogeneity in immune function due to adverse exposures in early life could plausibly contribute to infection susceptibility.
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Affiliation(s)
- Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Joice Tome
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Sandra Rukobo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Margaret Govha
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | - Farai S. Matimba
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | - Florence D. Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Naume V. Tavengwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Batsirai Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jean H. Humphrey
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Andrew J. Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Queen Mary University of London, London, United Kingdom
| | - Claire D. Bourke
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Centre for Genomics and Child Health, Queen Mary University of London, London, United Kingdom
- *Correspondence: Claire D. Bourke,
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