Symptoms of Refeeding Syndrome
Refeeding syndrome presents with fluid retention, electrolyte disturbances, and organ dysfunction that can be life-threatening when nutrition is reintroduced too aggressively in malnourished patients. 1
Clinical Symptoms
- Fluid retention manifesting as peripheral edema and potentially progressing to congestive heart failure 1
- Cardiac arrhythmias due to electrolyte imbalances, particularly from hypophosphatemia, hypokalemia, and hypomagnesemia 1
- Respiratory failure requiring increased ventilatory support 1
- Neurological manifestations including delirium, confusion, seizures, and encephalopathy 1
- Weakness and muscle dysfunction related to electrolyte abnormalities 2
- Lethargy that can progress to coma in severe cases 1
Laboratory Findings
- Hypophosphatemia - the most frequent and clinically significant electrolyte disturbance 1
- Hypokalemia - contributing to cardiac and neuromuscular complications 1
- Hypomagnesemia - often accompanying other electrolyte abnormalities 1
- Hypocalcemia - may occur alongside other electrolyte disturbances 1
- Disturbed glucose homeostasis with potential hypoglycemia if feeding is stopped abruptly 1
- Hyperlactatemia suggesting vitamin B1 (thiamine) deficiency 1
Timing and Presentation
- Symptoms typically develop within the first four days after nutrition therapy is commenced 1
- The syndrome can occur with any form of nutritional reintroduction (oral, enteral, or parenteral) 1
- Severity of symptoms correlates with the degree of prior malnutrition and the aggressiveness of refeeding 1, 3
Organ-Specific Manifestations
- Cardiovascular: Heart failure, arrhythmias, hypotension, sudden death 1, 4
- Pulmonary: Respiratory failure, difficulty weaning from mechanical ventilation 1
- Neurological: Wernicke's encephalopathy (from thiamine deficiency), confusion, seizures 1
- Hematologic: Hemolysis, thrombocytopenia, leukocyte dysfunction 5
- Hepatic: Liver dysfunction with excessive storage of fat and glycogen 1
High-Risk Patient Characteristics
- BMI <16 kg/m² 1, 3
- Unintentional weight loss >15% in 3-6 months 1
- Little or no nutritional intake for >10 days 1
- Low baseline levels of potassium, phosphate, or magnesium before feeding 1
- History of chronic alcoholism, anorexia nervosa, or severe malnutrition 1
- Patients with acute illness who are depleted 1
- History of chronic drug use (insulin, antacids, diuretics) 1
Prevention Considerations
- Careful identification of at-risk patients before initiating nutritional support 3
- Starting nutrition at low levels (5-10 kcal/kg/day) with slow progression over several days 1, 3
- Prophylactic supplementation of thiamine and other B vitamins before initiating feeding 1, 3
- Daily monitoring of electrolytes for the first several days of refeeding 3, 6
- Aggressive correction of electrolyte abnormalities before and during refeeding 1
The recognition of refeeding syndrome symptoms is critical as early intervention can prevent progression to life-threatening complications. Monitoring should be most intensive during the first four days of nutritional repletion, with particular attention to cardiac and respiratory function 1, 3.