Kwashiorkor and marasmus are two clinical syndromes observed in severe acute malnutrition. In this review, we highlighted the differences between these two syndromes by reviewing the data comparing kwashiorkor and marasmus in literature, combined with recent microbiological findings and meta-analysis. Depletion of antioxidants, vitamins and minerals were more severe in kwashiorkor than marasmus. This was consistent with the severe and uncontrolled oxidative stress associated with the depletion of gut anaerobes and the relative proliferation of aerotolerant gut pathogens. This relative proliferation and invasion of gut microbes belonging to the aerotolerant Proteobacteria phylum and pathogens suggested a specific microbial process critical in the pathogenesis of kwashiorkor. Liver mitochondrial and peroxisomal dysfunction could be secondary to toxic microbial compounds produced in the gut such as ethanol, lipopolysaccharides and endotoxins produced by Proteobacteria, particularly Klebsiella pneumoniae, and aflatoxin produced by Aspergillus species. The gut-liver axis alteration is characterized by oedema and a fatty and enlarged liver and was associated with a dramatic depletion of methionine and glutathione, an excessive level of free circulating iron and frequent lethal bacteraemia by enteric pathogens. This was consistent with the fact that antibiotics improved survival only in children with kwashiorkor but not marasmus. The specific pathogenic characteristics of kwashiorkor identified in this review open new avenues to develop more targeted and effective treatments for both marasmus and/or kwashiorkor. Urgent correction of plasma glutathione depletion, alongside supply of specific essential amino acids, particularly methionine and cysteine, early detection of pathogens and an antibiotic more efficient than amoxicillin in supressing gut Proteobacteria including K. pneumoniae, and probiotics to restore the human gut anaerobic mature microbiota could save many more children with kwashiorkor.

Kwashiorkor和Marasmus是在严重急性营养不良中观察到的两种临床综合征。在这篇综述中，我们通过回顾文献中比较kwashiorkor和marasmus的数据，结合最近的微生物学发现和荟萃分析，突出了这两种综合征之间的差异。在kwashiorkor中，抗氧化剂，维生素和矿物质的消耗比马拉斯莫斯更为严重。这与肠道厌氧菌耗竭和耐气性肠道病原体的相对增殖有关的严重且不受控制的氧化应激是一致的。这种相对增殖和侵袭肠道微生物属于耐氧变形菌门和病原体提示了在kwashiorkor发病机理中至关重要的特定微生物过程。肝线粒体和过氧化物酶体功能障碍可能是肠道产生的有毒微生物化合物继发的，例如乙醇，脂多糖和变形杆菌产生的内毒素，特别是肺炎克雷伯菌和曲霉产生的黄曲霉毒素种类。肠-肝轴改变的特征是水肿和肝脏脂肪肿大，并伴有蛋氨酸和谷胱甘肽的急剧消耗，游离循环铁水平过高和肠道病原体频繁致死菌血症。这与以下事实相吻合：抗生素仅能改善患有kwashiorkor患儿的存活率，而不能改善marasmus患儿的存活率。这篇综述中确定的kwashiorkor的特定致病性特征开辟了新的途径，以开发针对马拉维斯和/或kwashiorkor的更有针对性和更有效的治疗方法。血浆谷胱甘肽耗竭的紧急校正，沿着特定的必需氨基酸，特别是甲硫氨酸和半胱氨酸，病原体早期检测和在supressing肠道比阿莫西林一个更有效的抗生素供应变形菌包括肺炎克雷伯菌和能恢复人体肠道厌氧性成熟菌群的益生菌，可以为更多的患kwashiorkor的儿童挽救生命。