A paradoxical increase in resting energy expenditure in malnourished patients near death: the king penguin syndrome

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Abstract
Background: The metabolic expression of extreme starvation on the verge of death is unknown in humans. Objective: The objective was to compare the resting energy expenditure (REE) of 5 extremely malnourished dying patients [body mass index (in kg/m2): 9.77 ± 0.1] with that of 16 less-malnourished anorexia nervosa (AN) patients. Design: REE was measured by indirect calorimetry and body composition was measured by anthropometry and dual-frequency bioelectrical impedance analysis. Fasting serum insulin, thyroid hormone, and catecholamine concentrations were also determined. Results: At the start of refeeding, REE was high in each of the 5 extremely malnourished dying patients, whereas it was low in the 16 AN patients (x̄ ± SD: 5174 ± 391 kJ/d compared with 3844 ± 619 kJ/d; P < 0.05). The high REE value in the 5 extremely malnourished dying patients was associated with almost no fat mass (FM), high urinary nitrogen loss (16.4 ± 2.9 g/d), low serum fatty acid concentrations (0.36 ± 0.23 mmol/L), and low or normal serum insulin, thyroid hormone, and catecholamine concentrations. During the first 2–4 wk of refeeding, REE and nitrogen loss decreased, whereas fatty acid concentrations increased in each of the 4 surviving patients; REE and urinary nitrogen output increased in the 16 AN patients. Conclusion: In malnourished persons near death, there is an increase in REE and in protein catabolism. The reason for this increase is unknown but could relate to consumption of the last mobilizable muscle mass and to diseased cellular membranes.