Article

Review of the refeeding syndrome.

Department of Clinical Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109-0008, USA.
Nutrition in Clinical Practice (Impact Factor: 2.06). 01/2006; 20(6):625-33. DOI: 10.1177/0115426505020006625
Source: PubMed

ABSTRACT Refeeding syndrome describes a constellation of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications. We reviewed literature on refeeding syndrome and the associated electrolyte abnormalities, fluid disturbances, and associated complications. In addition to assessing scientific literature, we also considered clinical experience and judgment in developing recommendations for prevention and treatment of refeeding syndrome. The most important steps are to identify patients at risk for developing refeeding syndrome, institute nutrition support cautiously, and correct and supplement electrolyte and vitamin deficiencies to avoid refeeding syndrome. We provide suggestions for the prevention of refeeding syndrome and suggestions for treatment of electrolyte disturbances and complications in patients who develop refeeding syndrome, according to evidence in the literature, the pathophysiology of refeeding syndrome, and clinical experience and judgment.

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Available from: Michael D Kraft, Jul 28, 2015
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    • "It has been suggested that, ''A little nutrition support is good, too much is lethal'' [8]. "
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    ABSTRACT: Concerns about refeeding syndrome have led to relatively conservative nutritional rehabilitation in malnourished inpatients with anorexia nervosa (AN), which delays weight gain. Compared to other programs, we aggressively refed hospitalized adolescents. We sought to determine the incidence of hypophosphatemia (HP) in 12-18-year-old inpatients in order to inform nutritional guidelines in this group. A 1-year retrospective chart review was undertaken of 46 admissions (29 adolescents) with AN admitted to the adolescent ward of a tertiary children's hospital. Data collected over the initial 2 weeks included number of past admissions, nutritional intake, weight, height, body mass index, and weight change at 2 weeks. Serum phosphorus levels and oral phosphate supplementation was recorded. The mean (SD) age was 15.7 years (1.4). The mean (SD) ideal body weight was 72.9% (9.1). Sixty-one percent of admissions were commenced on 1,900 kcal (8,000 kJ), and 28% on 2,200 kcal (9,300 kJ). Four patients were deemed at high risk of refeeding syndrome; of these patients, three were commenced on rehydration therapy and one on 1,400 kcal (6,000 kJ). All patients were graded up to 2,700 kcal (11,400 kJ) with further increments of 300 kcal (1,260 kJ) as required. Thirty-seven percent developed mild HP; no patient developed moderate or severe HP. Percent ideal body weight at admission was significantly associated with the subsequent development of HP (p = .007). These data support more aggressive approaches to nutritional rehabilitation for hospitalized adolescents with AN compared to current recommendations and practice.
    Journal of Adolescent Health 06/2010; 46(6):577-82. DOI:10.1016/j.jadohealth.2009.11.207 · 2.75 Impact Factor
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    • "Severely malnourished patients (Table 1) appear to be at particular risk of developing the refeeding syndrome, whose features (Figure 1) (Travis et al., 1971; Craddock et al., 1974; O'Connor et al., 1977; Patrick, 1977; Heymsfield et al., 1978; Weinsier and Krumdieck, 1981; Powers, 1982; Isner et al., 1985; Cumming et al., 1987; Gustavsson and Eriksson, 1989; Faintuch, 1990; Beumont and Large, 1991; Brooks and Melnik, 1995; Birmingham et al., 1996; Marik and Bedigian, 1996; Paula et al., 1998; Crook et al., 2001; Hadley and Walsh, 2003; Marinella, 2003; Whyte et al., 2003; Hearing, 2004; Crook and Panteli, 2005; Kraft et al., 2005) include: salt and water retention leading to oedema and heart failure, which may be exacerbated by cardiac atrophy, Received 14 February 2007; revised 17 June 2007; accepted 21 June 2007; published online 15 August 2007 Correspondence: DN Lobo, Division of Gastrointestinal Surgery, Wolfson Digestive Diseases Centre, Nottingham University Hospitals, Queen's Medical Centre, Nottingham NG7 2UH, UK. E-mail: dileep.lobo@nottingham.ac.uk "
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    ABSTRACT: The refeeding syndrome is a potentially lethal complication of refeeding in patients who are severely malnourished from whatever cause. Too rapid refeeding, particularly with carbohydrate may precipitate a number of metabolic and pathophysiological complications, which may adversely affect the cardiac, respiratory, haematological, hepatic and neuromuscular systems leading to clinical complications and even death. We aimed to review the development of the refeeding syndrome in a variety of situations and, from this and the literature, devise guidelines to prevent and treat the condition. We report seven cases illustrating different aspects of the refeeding syndrome and the measures used to treat it. The specific complications encountered, their physiological mechanisms, identification of patients at risk, and prevention and treatment are discussed. Each case developed one or more of the features of the refeeding syndrome including deficiencies and low plasma levels of potassium, phosphate, magnesium and thiamine combined with salt and water retention. These responded to specific interventions. In most cases, these abnormalities could have been anticipated and prevented. The main features of the refeeding syndrome are described with a protocol to anticipate, prevent and treat the condition in adults.
    European Journal of Clinical Nutrition 07/2008; 62(6):687-94. DOI:10.1038/sj.ejcn.1602854 · 2.95 Impact Factor
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    • "We have found no previous references to associations of these alterations with gastrointestinal complications in critically ill patients. Both alterations can reduce intestinal motility and increase abdominal distention However, it is also possible that hypokalemia and hypophosphatemia are secondary to gastrointestinal intolerance or refeeding (Marik and Bedigian, 1996; Kraft et al., 2005), or owing to catecholamine administration (Body et al., 1983) or high cytokine levels (Barak et al., 1998). Our study has several limitations. "
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    ABSTRACT: To study the risk factors for gastrointestinal complications related to enteral nutrition in critically ill children. A prospective, observational study. Pediatric intensive care unit. Five hundred and twenty-six critically ill children who received transpyloric enteral nutrition(TEN). Univariate and multivariate logistic regression analysis were used to identify risk factors for gastrointestinal complications. Sixty six patients (11.5%) presented gastrointestinal complications, 33 (6.2%) abdominal distension and/or excessive gastric residue, 34 (6.4%) diarrhea, one gastrointestinal bleeding, three necrotizing enterocolitis and one duodenal perforation. Enteral nutrition was definitively suspended because of gastrointestinal complications in 11 (2.1%) patients. Fifty patients (9.5%) died. Gastrointestinal complications were more frequent in the patients who died. Death was related to complications of the nutrition in only one patient. The frequency of gastrointestinal complications was significantly higher in children with shock, acute renal failure, hypokalemia, hypophosphatemia and in those receiving dopamine, epinephrine and vecuronium. The stepwise multivariate logistic regression analysis showed that the most important factors associated with gastrointestinal complications were shock, epinephrine at a rate higher than 0.3 microg/kg/min and hypophosphatemia. The tolerance of TEN in critically ill children is good, although the incidence of gastrointestinal complications is higher in patients with shock, acute renal failure, hypokalemia, hypophosphatemia, and those receiving epinephrine, dopamine, and vecuronium.
    European Journal of Clinical Nutrition 04/2008; 62(3):395-400. DOI:10.1038/sj.ejcn.1602710 · 2.95 Impact Factor
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