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WASTING ≥ WEAKNESS

• Pathology
  • Often Muscle fiber atrophy: Type 2 > Type 1
  • Myonuclear domain: Smaller
• Type 2 fiber atrophy: Disorders
  • Cachexia (weight loss > 15%)
  • Sarcopenia
  • Aging
  • Disuse
  • Endocrine myopathies
    • Corticosteroid excess
    • Hyperthyroidism
  • Paraneoplastic Neuromyopathy
  • Metabolic
    • Testosterone: Low
• Prominent wasting associated with weakness: Other disorders
  • Congenital myopathies
  • Congenital myasthenic syndromes
  • Denervation
  • HIV wasting

SYSTEMIC DISORDERS WITH MUSCLE WASTING: Metabolic Changes

• Metabolic changes (Low CG syndrome)
  • Cystine & Glutamine: Low in plasma
  • Glutamate: Low in plasma
  • Glutathione: Low intracellular
  • Urea production: High
• Weight loss
  • Selectively in skeletal muscle
  • Not prevented by aggressive nutrition
• Natural killer cell function: Reduced
• Syndromes with low plasma cystine & glutamine levels
  • HIV: Late asymptomatic stage
  • Sepsis
  • Trauma
  • Bowel disease: Crohn's; Ulcerative colitis
  • Chronic fatigue syndrome
  • Overtraining
• Changes may be reversed by: N-acetyl-cystine (NAC) treatment
• Differs from starvation which has
  • Low urea production
  • Weight loss in most organs

Congenital myopathy Severe wasting involves the distal arms & legs. The most distal regions, the hands & feet, are relatively spared

• Severe wasting involves the distal arms & legs including the most distal regions, the hands & feet.
  
• Note atrophy of median (thenar) and ulnar innervated muscles in the hands.
  
• Severe trophic skin changes are present on the legs.

Spiller

Sarcopenia ¹

• Definitions
  • Sarcopenia
    • Features
      • Muscle mass: Reduced
      • Strength or Function: Reduced
      • Body composition
      • Course: Slow progression over adulthood
    • Associations
      • Age: Increased
      • Anatomical: Muscle fiber atrophy or loss
    • Classification
      • Primary: Age- & Sedentary lifestyle- related
      • Secondary: Related to obesity or acute disease
  • Pre-sarcopenia
    • Muscle mass: Reduced
    • Strength or Function: Normal
    • Association: Increased age
  • Muscle biomechanical quality = Strength/Mass
    • Aging: Strength loss > Reduced mass
    • Muscle biomechanical quality: Reduced
  • Muscle Depletion Syndromes (Sarcopenia +)

    Cachexia 3 Definitions Sarcopenia + Weight loss + Low BMI Wasting of Skeletal muscle ± Fat despite nutrition support Disease-related malnutrition with systemic inflammation Quantitative Weight loss ≥ 5% within 6 months 2% + Body mass index (BMI) <20 kg/M2 2% + Sarcopenia Laboratory C-reactive protein (CRP): > 1.0 mg/dL Albumin: < 3.5 g/dL Common with Advanced cancer: Accounts for 30% of deaths Effects Morbidity: Increased and reduces both Tolerance & Responsiveness to treatment: Reduced Cancer Cachexia: Associated with Bone morphogenetic protein (BMP) signaling: Reduced 4 Expression of Noggin (BMP inhibitor) increased in muscle Triggered by Activin A (IHNBA) IL-6 Cancer-mediated factors Proteolysis-inducing factor (PIF; Dermicidin; CCF1) Lipid-mobilizing factor (LMF; ZAG) TNF-α Parathyroid Hormone-like protein (PTHRP; PTHLP) Adipose wasting: UCP1 Anorexia & CNS Proopiomelanocortin (POMC) Cart Prepropeptide (CART; CARTPT)

    Cachexia Starvation Body Weight ↓ ↓ Skeletal   Muscle ↓ → Adipose   Tissue ↓ ↓ Rest Energy   Expenditure ↑ ↓ Inflammatory   Markers ↑ →

    • Sarcopenic-Obesity (SO) ⁶
      • Definition: Co-existence of Obesity & Sarcopenia ⁵
        • Obesity
          • Definition: Body mass or Waist circumference High
          • General frequency: 13%; ~1 billion individuals globally
          • Frequency > 65 years: 35%
          • Related to: Reduced muscle mass & quality
        • Sarcopenia: Clinical, Risks, or Criteria
      • Risks
        • For SO: Increased with age; Especially > 70 years
        • Of SO: Combination of 2 conditions
        • For: Frailty
      • Complications
        • Prognostic for: Increased Disability; Reduced survival
        • Disorders: Metabolic; Cardiovascular; Respiratory
        • Functional disability: Falls; Fatigue; Movement limitation
    • Frailty
      • Definition: Sarcopenia + Weight loss (Unintentional)
    • Dysmobility: Sarcopenia +
      • High fat mass
      • Osteoporosis
      • Falls: In past year
• Sarcopenia: Epidemiology
  • Population: ~ 70 million people world-wide
  • Prevalence
    • Healthy, > 65 years
      • Males: 0.5% to 5.3%
      • Females: 1.8% to 13.3%
    • Neoplasm
      • Solid tumor patients: 15% to 74%
      • Cancer, Pre-treatment: 19%
• Sarcopenia: Course
  • Onset age: May begin at 25 years
  • Age 40 years: 10% loss in muscle mass
  • Age ≥ 50 years
    • More rapid decline
    • 15% loss per decade
    • Age 70 years: 40% loss in muscle mass
  • May be reduced, or prevented, by: Physical activity
• Sarcopenia: Associations
  • Age: Increased frequency
    • 22% in males > 80 years
    • 9% to 20% in females > 80 years
  • Male-Female muscle quality differences
    • Related to % body fat
  • Disability
    • More associated with: Loss of Strength than Mass
  • Predictors of reduced muscle quality
    • Visceral obesity
    • Cognitive executive dysfunction
    • Nerve conduction velocity: Reduced
  • Sarcopenia: Higher prevalence
    • Smoking
    • Chronic obstructive pulmonary disease (COPD): 2x higher
    • Non-independent living
    • Less activity
    • Metabolic syndrome: 3 or more of
      • Obesity: Waist > 102 cm in men & > 88 cm in women
      • Triglycerides: High
      • High-density lipoprotein cholesterol: Low
      • Blood pressure > 130/85
      • Fasting plasma glucose: > 100 mg/dl
  • Possible association: Fracture risk increased
• Laboratory
  • Motor unit potentials: Amplitudes reduced with sarcopenia
  • MUNE: Motor unit size smaller
  • ACTN3 XX genotype: Gait more slowed with age
  • Muscle
    • Morphology
      • Muscle fiber atrophy: Type 2 more than type 1
      • Also see: Aging changes in muscle
    • Mitochondrial ²
      • Age-related: Complex I activity reduced
      • Muscle fiber atrophy-related: Complex I, II ± III activities reduced
• Sarcopenia: Quantitation & Imaging
  • Muscle mass: Dual X-ray absorptiometry (DXA)
    • Measures
      • Appendicular Lean Mass (ALM) / Height²
      • ALM / Body Mass Index (BMI)
    • Muscle Manifestations in Sarcopenia
      • Size: Reduced
      • Fat: Increased
  • Muscle mass: Other imaging methods
    • Bioelectrical impedance analysis (BIA)
    • Computed Tomography (CT)
    • Ultrasound
  • Reduced strength or Physical performance
    • Some patients
    • Handgrip quantitation
      • Males: ≤ 26 to 32 kg (57 to 70 lbs) depending on BMI (24 to 28)
      • Females: ≤ 16 to 21 kg (35 to 46 lbs) depending on BMI (23 to 29)
    • Gait speed
      • Males: ≤ 0.65 m/s to 0.76 depending on height (≤ 173 cm)
      • Females: ≤ 0.65 m/s to 0.76 depending on height (≤ 159 cm)
    • Short Physical Performance Battery (SPPB)
      • Standing & Walking: Tandem
      • Standing & Sitting from Chair

Sarcopenia: Muscle Pathology

H&E stain

ATPase ph 9.4 stain