Review articleThe importance of the refeeding syndrome1
Introduction
In urbanized industrialized countries, where obesity is now becoming more commonplace, it might appear paradoxical that patients can still present with the “refeeding syndrome.” This potentially lethal condition can be defined as severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing refeeding orally, enterally, or parenterally.1, 2
Although previous reports had emphasized severe hypophosphatemia as a predominant feature of the refeeding syndrome, it has now become apparent that there are other metabolic consequences that are important such as fluid-balance abnormalities, altered glucose metabolism, and certain vitamin deficiencies, e.g., thiamine, as well as hypokalemia and hypomagnesemia (Table I).
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Patients at high risk for the refeeding syndrome
Historically, some of the earliest reports of the refeeding syndrome occurred in starved patients in wartime such as Japanese prisoners and victims of the Leningrad or Netherlands famines.3 In general, those individuals with marasmus or kwashiorkor are at risk for the refeeding syndrome, particularly if there is greater than 10% weight loss over a couple of months. Patients are at risk if they have not been fed for 7 to 10 d, with evidence of stress and depletion. However, more specifically,
Pathogenic mechanisms involved in the refeeding syndrome
It is useful to review some basic physiologic processes that take place during starvation because this will help to explain some of the clinical manifestations observed in the refeeding syndrome.
Insulin concentrations decrease while glucagon increases during starvation. This results in the rapid conversion of glycogen stores to form glucose as well as gluconeogenesis, resulting in glucose synthesis via lipid and protein breakdown products. Adipose tissue releases large quantities of fatty acids
Disturbances of body-fluid distribution
The metabolic abnormalities, principally electrolyte and fluid disturbances, resulting from the refeeding syndrome can influence many body functions.
The fluid intolerance can result in cardiac failure, dehydration or fluid overload, hypotension, prerenal failure, and sudden death. Refeeding with carbohydrate can reduce water and sodium excretion, resulting in expansion of the extracellular-fluid compartment and weight gain, particularly if sodium intake is increased. Refeeding with
Clinical relevance of the metabolic derangements in the refeeding syndrome
The total incidence of the refeeding syndrome has been put at as high as about 25% in cancer patients who are nutritionally supported.69 That study also reported that the syndrome was more common in those fed enterally than parentrally and tended to manifest in the first few days after commencement of feeding. Further, it is more common in the elderly, although mortality figures per se are difficult to establish accurately because patients often have other underlying disease states.70
The
Prevention and management of the refeeding syndrome
Not all patients who are refed develop the refeeding syndrome. It is important to be aware of the condition and anticipate problems to help minimize its occurrence. Hospital nutrition teams have an important role in the recognition, education, and management of the refeeding syndrome.78 It is important to closely monitor at-risk patients, in particular their vital functions, fluid balance, and plasma electrolytes including magnesium and phosphate. Electrocardiographic monitoring can be useful
Conclusions
The refeeding syndrome unfortunately is encountered in modern clinical practice and is relatively poorly recognized or understood. The pathophysiologic processes include disturbances of glucose and fluid balance and electrolyte disorders that involve mainly the intracellular ions, namely phosphate, potassium, and magnesium. Despite being potentially preventable, it is associated with high morbidity and mortality. Nutrition teams can help to provide advice and education in its prevention,
Postscript
Recently, a paper by Faintuch and colleagues in this journal looked at refeeding of hunger-strikers.91 Using a modified refeeding regime92, 93 they were able to minimize electrolyte disturbances although episodes of diarrhea and some fluid retention were noticed. Interestingly, acute-phase markers were elevated during the refeeding time.
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Disclaimer: It is recommended that readers check drug and electrolyte dosages and concentrations with their pharmacies before patient administration. The authors accept no responsibility for errors in the article.