From the Guidelines
Refeeding syndrome is a life-threatening condition that presents with symptoms such as fluid retention, congestive heart failure, cardiac arrhythmia, respiratory failure, delirium, and encephalopathy, primarily due to severe electrolyte imbalances, particularly hypophosphatemia, hypokalemia, and hypomagnesemia, which can occur within the first four days of nutrition therapy in malnourished individuals. The clinical manifestations of refeeding syndrome can be severe and include:
- Fluid retention with peripheral edema
- Congestive heart failure
- Cardiac arrhythmia
- Respiratory failure
- Delirium
- Encephalopathy
- Other severe organ dysfunctions These symptoms are often precipitated by the rapid reintroduction of nutrition in individuals who are malnourished, such as those with chronic alcoholism, severe chronic undernutrition, anorexia nervosa, or depleted patients with acute illness 1. Key diagnostic criteria for refeeding syndrome include:
- Fluid imbalance
- Disturbed glucose homeostasis
- Hyperlactatemia suggesting vitamin B1 deficiency
- Hypophosphatemia, hypomagnesemia, and hypokalaemia It is crucial to screen patients at risk of refeeding syndrome, including those with a BMI <16 kg/m2, unintentional weight loss >15% in 3-6 months, little or no intake for >10 days, or low potassium, phosphate, and magnesium before feeding 1. To prevent refeeding syndrome, it is essential to reintroduce nutrition gradually in at-risk patients, starting at approximately 25% of caloric needs and increasing slowly over several days while closely monitoring electrolytes, and providing prophylactic supplementation of phosphate, potassium, magnesium, and thiamine as necessary 1.
From the Research
Symptoms of Refeeding Syndrome
The symptoms of refeeding syndrome can be severe and life-threatening, and include:
- Neurological alterations 2
- Respiratory symptoms 2
- Arrhythmias 2
- Heart failure 2, 3
- Hypophosphatemia (low serum concentrations of phosphate) 4, 2, 5, 3, 6
- Hypokalemia (low serum concentrations of potassium) 4, 2, 5, 3
- Hypomagnesemia (low serum concentrations of magnesium) 4, 2, 5, 3
- Muscle weakness 3
- Immune dysfunction 3
Clinical Manifestations
The clinical manifestations of refeeding syndrome can occur few days after refeeding 2, and may include:
- Severe electrolyte disturbances 4, 2, 5, 3, 6
- Metabolic abnormalities 4, 2, 5, 3, 6
- Cardiac failure 3
- Death 3
Diagnosis and Prevention
The diagnosis of refeeding syndrome is not facilitated by the fact that there is no universal agreement as to its definition 4, and the presence of hypophosphatemia alone does not necessarily mean that refeeding syndrome is present 4. However, careful patient monitoring and multidiscipline nutrition team management may help to achieve early recognition and reduce morbidity and mortality 4, 2, 5.