From the Guidelines
Refeeding syndrome symptoms can occur in individuals who are malnourished or have undergone significant caloric restriction, and then begin to receive nutrition, and may include hypophosphatemia, hypokalemia, and hypomagnesemia 1.
Common Symptoms
- Fluid retention with peripheral oedema
- Congestive heart failure
- Cardiac arrhythmia
- Respiratory failure
- Delirium
- Encephalopathy
- Other severe organ dysfunctions These symptoms can be managed with careful monitoring and supplementation, such as phosphate replacement with potassium phosphate 1-2 mmol/kg/day, and magnesium replacement with magnesium sulfate 1-2 g/day 1.
Risk Factors
- Chronic alcoholism
- Severe chronic undernutrition
- Anorexia nervosa
- Depleted patients with acute illness
- BMI < 16 kg/m2
- Unintentional weight loss > 15% in 3-6 months
- Little or no intake for > 10 days
- Low potassium, phosphate, and magnesium before feeding In severe cases, thiamine supplementation with thiamine hydrochloride 100-200 mg/day may also be necessary to prevent Wernicke's encephalopathy 1.
Prevention
Prevention of refeeding syndrome is crucial, and this can be achieved by supplying vitamin B1 in daily doses of 200-300 mg, as well as a balanced micronutrient mixture 1.
Monitoring
Close monitoring of volume of circulation, fluid balance, heart rate, and rhythm, as well as clinical status, is essential during nutritional repletion 1.
From the Research
Symptoms of Refeeding Syndrome
The symptoms of refeeding syndrome can be varied and unspecific, but typical features include:
- Hypophosphatemia, hypokalemia, hypomagnesemia, and thiamine deficiency 2, 3, 4, 5, 6
- Electrolyte imbalances that can occur in malnourished and abruptly refed patients 2
- Weakness, seizures, and even heart failure due to the sudden increase in food intake causing a shift in the body's metabolism and electrolyte balance 2
- Cardiac arrhythmias, multisystem organ dysfunction, and death in severe cases 3
- Delirium, particularly in geriatric patients 4
- Sodium/water retention and thiamine deficiency with the risk of Wernike's encephalopathy/Korsakoff psychosis 5
Risk Factors and Prevention
Refeeding syndrome can be effectively prevented and treated if its risk factors and pathophysiology are known, including:
- Malnutrition, weight loss, chemotherapy, diuretics, and alcoholism as risk factors 4
- Close monitoring of electrolyte levels and prophylactic use of dietary supplements such as thiamine to correct any imbalances that may occur 2, 6
- Slow increase in nutritional intake along with close monitoring of serum electrolytes 3, 5, 6
- Generous vitamin and electrolyte supplementation while monitoring closely and increasing the calorie intake reasonably rapidly 5