From the Guidelines
Refeeding syndrome is characterized by severe electrolyte and fluid imbalances, particularly hypophosphatemia, hypokalemia, and hypomagnesemia, which can lead to life-threatening complications such as cardiac arrhythmias, heart failure, and respiratory failure, and typically occurs within the first four days after nutrition therapy is commenced. The symptoms of refeeding syndrome can include:
- Fluid retention with peripheral edema
- Congestive heart failure
- Cardiac arrhythmia
- Respiratory failure
- Delirium
- Encephalopathy
- Other severe organ dysfunctions as noted in the espen guidelines on definitions and terminology of clinical nutrition 1. These symptoms are often precipitated by the sudden shift from fat to carbohydrate metabolism when feeding resumes, causing insulin release that drives electrolytes into cells and depletes circulating levels. Patients at high risk of refeeding syndrome include those with chronic alcoholism, severe chronic undernutrition, anorexia nervosa, or depleted patients with acute illness, and can be identified by screening for factors such as low BMI, unintentional weight loss, little or no intake for an extended period, or low potassium, phosphate, and magnesium before feeding 1. Prevention and management of refeeding syndrome involve gradual refeeding with careful electrolyte monitoring and replacement, starting at approximately 25% of caloric needs and increasing gradually while monitoring electrolytes daily for at least the first week of refeeding.
From the Research
Symptoms of Refeeding Syndrome
The symptoms of refeeding syndrome can be severe and life-threatening, and may include:
- Hypophosphatemia, which can lead to cardiac failure, muscle weakness, and immune dysfunction 2
- Hypokalemia and hypomagnesemia, which can complicate refeeding syndrome and lead to further complications 2, 3
- Thiamine deficiency, which can lead to Wernike's encephalopathy/Korsakoff psychosis 4
- Sodium/water retention, which can lead to further complications 4
- Organ dysfunctions, which can occur due to abnormal electrolyte and fluid shifts 5
Clinical Manifestations
The clinical manifestations of refeeding syndrome can vary in severity and may be absent or mild in some cases, but can also be severe and life-threatening in others 5. The symptoms may appear within 2-5 days of re-feeding and can depend on the pre-existing degree of malnutrition and comorbidities 5.
Electrolyte Disturbances
Refeeding syndrome is characterized by severe electrolyte disturbances, including:
- Hypophosphatemia, which is a key feature of the syndrome 6, 2, 3
- Hypokalemia, which can occur due to the shift of potassium into cells during refeeding 2, 3
- Hypomagnesemia, which can also occur due to the shift of magnesium into cells during refeeding 2, 3
Importance of Early Recognition
Early recognition of refeeding syndrome is crucial to reduce morbidity and mortality, and to prevent further complications 6, 5. A high clinical suspicion is necessary when refeeding any malnourished patient, and generous vitamin and electrolyte supplementation may be given while monitoring closely 4.