Albumin is a relatively small protein, so it contributes disproportionately to the plasma oncotic

pressure, and in health is its major contributor. Starling's equation explains how the movement
and distribution of water between the plasma and tissue spaces of all tissues is physically
regulated by the balance of hydrostatic and oncotic pressures across capillary blood vessel
walls. However, Golden ruled out this mechanism as the primary cause for oedema in
kwashiorkor

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462841/

Bittot spot is superficial foamy white spots on the conjunctiva\\

Textbook of Clinical Pediatrics

Oleh A. Y. Elzouki,H. A. Harfi,H. Nazer,William Oh,F. B. Stapleton,R. J. Whitley

https://books.google.co.id/books?id=FEf4EMjYSrgC&pg=PA715&lpg=PA715&dq=kwashiorkor+
hIPOALBUMINEMIA&source=bl&ots=ptCY-
9oNpm&sig=IIBPQqfD5NAmhHJcVYGBvSsp_6M&hl=id&sa=X&ved=0ahUKEwix2v7jnNbTAhUIMI
8KHUavBawQ6AEIaTAJ#v=onepage&q=kwashiorkor%20hIPOALBUMINEMIA&f=false

oxygen-hemoglobin dissociation curve, 2,3-diphosphoglycerate (2,3-DPG), and adenosine

triphosphate (ATP) have been studied in marasmic kwashiorkor before re-feeding, after re-
feeding, and in control children. P 50 and 2,3-DPG level are normal on admission, but high after
re-feeding. Patients studied on admission were separated into 2 groups according to whether
they presented active erythropoiesis (group I) or erythroblastopenia (group II). In group I, the
sum 2,3-DPG + ATP correlates with the hemoglobin level. In group II, the sum 2,3-DPG + ATP
correlates with the blood pH but not with the hemolobin level. It is suggested that marasmic
kwashirokor anemia is an adaptation to a reduced metabolic activity. The hematological picture
could proceed in 2 stages in this disease. In a first stage, the erythropoiesis is normal or
increased because of the existence of a decreased red cell life span; a low hemoglobin level is
observed, but there is no apparent hypoxia. At a more advanced stage of the disease, the tissue
metabolism falls dramatically, the erythropoiesis is no loner stimulated, and the erythrocyte
volume decreases notably.

https://www.ncbi.nlm.nih.gov/pubmed/819052

Anemia pada malnutrisi berat biasanya bersifat normokromik dan tidak disertai oleh
retikulositosis meskipun cadangan Fe cukup adekuat. Penyebab anemia pada anak yang asupan
proteinnya tidak adekuat adalah karena menurunnya sintesis eritopoeietin, sedang apabila
tidak mengasup protein sama sekali karena timbul stem cell pada sumsum tulang belakang
yang tidak berkembang, dan juga penurunan produksi eritopoeietin. Hipoproteinemia, keadaan
ini menyebabkan kekurangan produksi eritropoietin akibatnya Produksi eritrosit juga
berkurang. Hipoproteinemia juga bisa menyebabkan stem sel tidak berkembang. Dimana stem
sel ini yang berdiferensiasi menjadi CFU-S (unit pembentuk koloni limpa), CFU-B (unit
pembentuk koloni blas), kemudian baru membentuk CFU-E (unit pembentuk koloni eritrosit).
Eritrosit mengandung hemoglobin (Hb) yang mengangkut O 2 dari paru-paru ke jaringan.
Jumlah total eritrosit dalam sirkulasi diatur sedemikian rupa agar cukup untuk menyulai O 2 ke
seluruh jaringan. Sehingga bila stem sel tersebut tidak berkembang maka pada ujungnya akan
terjadi anemia.

kelainan pada sel-sel epietl pada selaput lendirmata akibar kekurangan vitamin
A karena adanya metaplasias e l -
sel epitel , sehingga menyebabkan kelenjar tidakm
emproduksi cairan Bitot spot merupakan keratinisasi lebihlanjut dari epitel
konjungtiva

Bitot's spot is highly suggestive of vitamin A deficiency and, sometimes, chronic

conjunctival inflammation. The condition is characterized by metaplasia of the
conjunctival epithelium and tangles of keratin admixed with gas-forming bacteria
(e.g., Corynebacterium xerosis), giving the lesion its typical foamy appearance. The
serum level of vitamin A in this patient was extremely low, at <2 μg per deciliter (0.07
μmol per liter; normal range, 30 to 70 μg per deciliter [1 to 2 μmol per liter]); he was
given vitamin A supplementation. Vitamin A deficiency affects approximately 140 million
children worldwide, making it the second most prevalent nutritional disorder after caloric
malnutrition; in developed countries, it can be associated with fat malabsorption. At
follow-up approximately 12 months after diagnosis, slit-lamp examination revealed
complete healing of the lesion (Panel B), and symptoms were substantially improved.

The mechanism for anemia in kwashiorkor have been examined in several laboratories.
Protein deficiency leads to reduction in oxygen consumption and erythropoietin
production, with a subsequent drop in erythropoiesis and reticulocyte count. Red cell
maturation is blocked at the erythroblast level and the erythropoietin sensitive stem cell
pool is slightly decreased.