Association between energy delivery from parenteral nutrition and refeeding syndrome in hospitalized adults: A retrospective cohort study.

BACKGROUND: Patients receiving parenteral nutrition (PN) may develop refeeding syndrome (RFS). This study determined RFS prevalence in hospitalized adults on PN and evaluated whether higher energy delivered by PN on day 1 of PN initiation was associated with RFS development. METHODS: We reviewed the medical records of adult patients receiving PN at a Thai quaternary hospital from June 2019 to May 2022. RFS was defined based on the Nutrition Management Clinical Practice Recommendation by the Society of Parenteral and Enteral Nutrition of Thailand. The association between PN energy delivery and RFS development was determined using a generalized estimating equation for multiple logistic regression analysis adjusted for NICE guideline risk factors. RESULTS: A total of 547 patients was included (mean age 59.8 ± 17.2 years, mean body mass index 20.7 ± 4.8 ). The prevalence of RFS was 45%. Factors associated with RFS included energy from PN on the first day of PN initiation (adjusted odds ratio [aOR] 1.17; 95% CI 1.04-1.33; for every 5 kcal/kg/day increase), starvation >5 days prior to PN (aOR 1.54; 95% CI 1.04-2.26), concomitant diuretic use (aOR 1.81; 95% CI 1.25-2.64), low baseline potassium level (aOR 1.79; 95% CI 1.19-2.70), and individual compounding PN (aOR 1.61; 95% CI 1.04-2.51). CONCLUSION: RFS was common among hospitalized patients receiving PN. The amount of energy delivered on the first day of PN was independently associated with RFS, raising a concern regarding initiation of PN with higher energy.

Incidence of hypophosphataemia after ICU admission in mechanically ventilated patients and its relationship with risk factors for refeeding syndrome.

OBJECTIVE: To describe the incidence of hypophosphatemia in patients admitted to the ICU who have required mechanical ventilation. To analyze the presence of risk factors and its relationship with nutritional practice. DESIGN: Prospective observational study. SETTING: Polyvalent ICUs of 2 University Hospitals. PATIENTS OR PARTICIPANTS: Patients on invasive mechanical ventilation ≥72 h with normal level of phosphorus at admission. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Electrolyte levels (phosphorus, magnesium, potassium) were determined on admission to the ICU and at 96 h. Risk categories on admission, caloric intake, insulin doses and acid-base status during the first 4 days of admission were recorded. Incidence was calculated as the number of patients who developed hypophosphataemia after admission. Univariate analysis was performed for between-group comparison and multivariate analysis of potential risk factors. RESULTS: 89 patients were included. The incidence of hypophosphataemia was 32.6%. In these patients phosphorus decreased from 3.57 ±â€¯1.02 mmol/l to 1.87 ±â€¯0.65 mmol/l (52.3%). The mean kcal/kg/24 h provided in the first 4 days was 17.4 ±â€¯4.1, with no difference between the group that developed hypophosphataemia and the group that did not. Significant risk factors were insulin doses administered and pH and PaCO2 values. CONCLUSIONS: The incidence of hypophosphataemia at 96 h from admission in mechanically ventilated patients is high and unrelated to the risk category and hypocaloric nutritional practice used. Insulin dosis and acid-base status are the main determinants of its occurrence.

The incidence of refeeding syndrome and the nutrition management of severely malnourished inpatients with eating disorders: An observational study.

OBJECTIVE: Nutritional rehabilitation and weight restoration are often critical for the treatment of eating disorders (ED), yet are restricted by the potential risk of refeeding syndrome (RFS). The primary objective was to determine the incidence of RFS. Secondary objectives were to explore predictive factors of RFS and describe its impact on treatment goals for patients with ED. METHOD: This retrospective observational study reviewed the nutrition management for patients admitted to a quaternary hospital for ED treatment from 2018 to 2020. Data were collected during the first 4 weeks of admission and included anthropometry, energy prescription, incidence and severity of RFS, and electrolyte and micronutrient prescription. Outcomes included incidence of RFS, energy prescription and advancement, and weight change. RESULTS: Of 423 ED admissions, 217 patients (median [interquartile range, IQR] age 25 [21-30.5] years; 210 [97%] female) met inclusion criteria. Median (IQR) body mass index (BMI) on admission was 15.5 (14.1-17.3) kg/m2 . The mean (standard deviation) length of admission was 35 (7.3) days. Median (IQR) initial energy prescription was 1500 (930-1500) kcal/day. Seventy-three (33%) patients developed RFS; 34 (16%) mild, 27 (12%) moderate, and 12 (5%) severe. There was no association between RFS severity and admission BMI, energy prescription, or prescription of prophylactic electrolytes or micronutrients. Lower admission weight was associated with RFS (odds ratio 0.96, 95% confidence interval [0.93-1.00], p = .035). Less than half of the participants met the weight gain target (>1 kg per week) in the first 3 weeks of admission. DISCUSSION: The incidence of severe RFS was low in this cohort and was associated with lower admission weight. PUBLIC SIGNIFICANCE: This study is one of the largest studies to utilize consensus-defined criteria to diagnose RFS among adult patients admitted for treatment of an ED. This population is still considered to be at risk of RFS and will require close monitoring. The results add to the growing body of research that restriction of energy prescription to prevent RFS may not require the level of conservatism traditionally practiced.

Characterization of refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa: A systematic review.

PURPOSE: To characterize and compare, through descriptive analysis, existing refeeding protocols for under 18 years old hospitalized patients with anorexia nervosa (AN). METHODS: This is a systematic review of PubMed, Cochrane, SciELO, Lilacs and BVS databases, without search period restriction. Studies were selected in accordance with pre-defined eligibility criteria and according to the Population, Intervention, Comparator, Outcome and Study Design (PICOS). RESULTS: Twenty articles out of 412 found complied with PICOS eligibility criteria and were included in the final review. Most of the studies were observational or retrospective and 80% were published in the last decade. Large variability in relation to sample size, refeeding protocols and length of stay were observed between studies. CONCLUSION: All included studies had several methodological limitations and heterogeneous designs, making it difficult to establish conclusive guidelines regarding the most adequate and effective refeeding protocol for under 18 years old hospitalized patients with AN. Prospective trials are necessary to straight compare standard refeeding protocols for this population.

Nutritional Status, Refeeding Syndrome and Some Associated Factors of Patients at COVID-19 Hospital in Vietnam.

Multisystem inflammatory syndrome is associated with COVID-19 and can result in reduced food intake, increased muscle catabolism, and electrolyte imbalance. Therefore COVID-19 patients are at high risk of being malnourished and of refeeding syndrome. The present study aimed to determine the prevalence and correlates of malnutrition and refeeding syndrome (RS) among COVID-19 patients in Hanoi, Vietnam. This prospective cohort study analyzed data from 1207 patients who were treated at the COVID-19 hospital of Hanoi Medical University (HMUH COVID-19) between September 2021 and March 2022. Nutritional status was evaluated by the Global Leadership Initiative on Malnutrition (GLIM) and laboratory markers. GLIM-defined malnutrition was found in 614 (50.9%) patients. Among those with malnutrition, 380 (31.5%) and 234 (19.4%) had moderate and severe malnutrition, respectively. The prevalence of risk of RS was 346 (28.7%). Those with severe and critical COVID symptoms are more likely to be at risk of RS compared to those with mild or moderate COVID, and having severe and critical COVID-19 infection increased the incidence of RS by 2.47 times, compared to mild and moderate disease. There was an association between levels of COVID-19, older ages, comorbidities, the inability of eating independently, hypoalbuminemia and hyponatremia with malnutrition. The proportion of COVID-19 patients who suffered from malnutrition was high. These results underscore the importance of early nutritional screening and assessment in COVID-19 patients, especially those with severe and critical infection.

Narrative review of inpatient nutritional management of anorexia nervosa with management recommendations for Australian tertiary health services.

BACKGROUND: Patients with anorexia nervosa (AN) may experience life-threatening malnutrition-related complications requiring inpatient medical stabilisation. Several management guidelines have been developed but discrepancies exist because of limited high-level evidence. AIMS: To review the evidence base for recommendations contained in Victorian health services guidelines for the nutritional management of inpatients with AN. METHODS: MEDLINE and Embase databases were searched for published studies on the nutritional management of inpatients with AN, combined with a manual search through citations. Studies including patients with AN aged 16 years and older were included. Case reports, small case series of <10 patients, studies of nonmedical management and studies with an exclusive paediatric population were excluded. The search results were compared with AN inpatient medical management guidelines sourced from large tertiary health services across Victoria, Australia. RESULTS: The search yielded 584 studies, subsequently reduced to nine studies using the inclusion and exclusion criteria. The results suggest that commencing refeeding at a higher caloric value allows faster weight gain and shorter hospitalisation. Enteral tube feeding is preferential to parenteral nutrition because of infrequent and milder complications. Zinc supplementation showed a doubled rate of body mass index increase compared with placebo. Comparison with Victorian health services guidelines revealed inconsistent recommendations for high-calorie refeeding and micronutrient supplementation. CONCLUSION: The evidence supports high-calorie refeeding of 2000 kcal/day in AN inpatient medical management and zinc supplementation in improving the rate of weight restoration. This is inconsistently reflected in different Victorian health services guidelines. Updated national consensus guidelines could assist in improving consistency of evidence-based health care.

Renal fluid and acid/base balance during refeeding in restrictive eating disorders.

BACKGROUND AND OBJECTIVES: Fluid shifts have been ascribed to central diabetes insipidus in patients with anorexia nervosa hospitalized for refeeding. Recent data, however, suggest that vasopressin production is not dysregulated in this population. Our objective was to describe the trajectory of fluid imbalances in relationship to kidney function, electrolyte disturbances, and acid/base balance during refeeding. METHODS: A retrospective review of daily fluid balance and biochemical values was performed in 70 sequential unique patients admitted to University of California at Los Angeles Hospital Medical Stabilization Program for Eating Disorders from December 2018 to November 2020. RESULTS: Participants (2 males/68 females) were between 10 and 24 years of age and with a median body mass index of 16.1 (14.3, 18.1) kg/m2 . A severe negative fluid balance (>-900 ml/day) was observed in 80% of patients at some point during hospitalization. Serum sodium concentrations were normal on admission and remained stable during refeeding. Serum bicarbonate concentrations were 25 ± 1 mEq/dl on admission and increased above the normal range in 31% of patients. Metabolic alkalosis was inversely associated with the development of a negative fluid balance. Estimated glomerular filtration rate was impaired in 54% of patients, improved with refeeding, and was not associated with the development of a severe negative fluid balance or metabolic alkalosis. DISCUSSION: Chronic energy deprivation alters the physiology of renal fluid and bicarbonate handling in ways that are independent of vasopressin and glomerular filtration. Further studies are warranted to understand the renal adaptations that occur during energy restriction and subsequent refeeding. PUBLIC SIGNIFICANCE: Massive urinary fluid losses occur in patients with restrictive eating disorders hospitalized for refeeding. In addition, many patients have impaired renal bicarbonate excretion. These findings suggest that chronic energy deprivation impairs the kidney's ability to handle the shifts in fluid and acid/base balance that occur when appropriate oral nutrition is re-introduced.

Safe Management by a Pop-Up Eating Disorder Team.

Background Anorexia nervosa has a high mortality complicated by risks of under-nourishment, over-nourishment and care can be compromised by behavioural issues. Methods This is a retrospective study of ten patients with eating disorders admitted to Sligo University Hospital, treated by a "pop-up"/on demand multidisciplinary eating disorder team. Results All were female, mean BMI on admission was 14.35kg/m2, on discharge was 16.59kg/m2, (p=0.001) and was significantly lower than the initial measurement and may represent water-loading or bowel retention. Admission biochemistry was normal in nine subjects. Six subjects experienced refeeding syndrome, one was hypoglycaemic (3.1mmol/L) in the setting of an aspiration pneumonia, and five exhibited treatment avoiding behaviour including food caching, micro exercising. The mean length of stay was 38 days and was positively correlated with weight gain during admission (p=0.02). 6-month follow up BMI was higher than admission in eight subjects and the other two voluntarily withdrew from follow-up. Conclusion There was a high incidence of treatment avoiding behaviour, initial weights were misleadingly high, admission biochemistry misleadingly normal, hypoglycaemia associated with infection, and incidence of refeeding syndrome is high. Notwithstanding this these patients can be managed safely and effectively in a general hospital with a coordinated, well-structured approach by a multidisciplinary team.

Incidence and Impact of Refeeding Syndrome in an Internal Medicine and Gastroenterology Ward of an Italian Tertiary Referral Center: A Prospective Cohort Study.

Background: Refeeding syndrome (RS) is a neglected, potentially fatal syndrome that occurs in malnourished patients undergoing rapid nutritional replenishment after a period of fasting. The American Society for Parenteral and Enteral Nutrition (ASPEN) recently released new criteria for RS risk and diagnosis. Real-life data on its incidence are still limited. Methods: We consecutively enrolled patients admitted to the Internal Medicine and Gastroenterology Unit of our center. The RS risk prevalence and incidence of RS were evaluated according to ASPEN. The length of stay (LOS), mortality, and re-admission rate within 30 days were assessed. Results: Among 203 admitted patients, 98 (48.3%) were at risk of RS; RS occurred in 38 patients (18.7% of the entire cohort). Patients diagnosed with RS had a higher mean LOS (12.5 days ± 7.9) than those who were not diagnosed with RS (7.1 ± 4.2) (p < 0.0001). Nine patients (4.4%) died. Body mass index (OR 0.82; 95% CI 0.69−0.97), RS diagnosis (OR 10.1; 95% CI 2.4−42.6), and medical nutritional support within 48 h (OR 0.12; 95% CI 0.02−0.56) were associated with mortality. Conclusions: RS incidence is high among clinical wards, influencing clinical outcomes. Awareness among clinicians is necessary to identify patients at risk and to support those developing this syndrome.

Rapid refeeding in anorexia nervosa: A dialectic balance.

OBJECTIVE: To examine the impact of our new rapid refeeding protocol on patients with anorexia nervosa (AN) in our Eating Disorders Program. We hypothesize that the new protocol would lead to a more rapid weight gain and a shorter length of stay, with no effect on medical complications or program completion. METHOD: This cohort design included consecutive inpatients and day hospital patients admitted to the program with a BMI <18 kg/m2 and a diagnosis of AN between 2007 and 2020; N = 326 patients. Main outcomes measured were rate of weight gain and length of stay. Safety indicators included electrolyte disturbances and supplementation required, complications including refeeding syndrome and completion of the program. A p value <.05 was considered statistically significant. RESULTS: Total length of stay was 21 days shorter for patients on the rapid refeeding protocol compared to the traditional refeeding protocol. Patients on the new protocol gained 0.21 more kg/week compared to patients on the old protocol. There was no difference in completion rates between programs. Electrolyte imbalances were mild to moderate and easily treated with oral electrolyte supplementation. There were no deaths or cases of refeeding syndrome with either protocol. DISCUSSION: This is the first Canadian study to assess the effectiveness and safety of rapid refeeding in an adult population. Rapid refeeding protocols can be safely administered and are cost effective. Shorter hospital admissions are desirable to minimize possible regression and dependency on inpatient services and positively impacts patients' quality of life. PUBLIC SIGNIFICANCE: This study advances the idea that rapid refeeding in patients with anorexia nervosa can be administered safely and effectively with close medical monitoring. In addition, rapid refeeding leads to shorter hospital stays, with a cost-savings to the health system. Shorter admissions are desirable to minimize possible regression and dependency on inpatient services and also positively impacts patients' quality of life.

Impact of caloric prescriptions and degree of malnutrition on incidence of refeeding syndrome and clinical outcomes in patients with eating disorders: A retrospective review.

BACKGROUND: For individuals with eating disorders (EDs), medical stabilization is paramount for restoration of body weight. Careful nutritional rehabilitation minimizes risk of refeeding syndrome. Study's purpose: describe clinical outcomes of pediatric/adolescent patients with EDs treated with lower calorie (<1300 kcals/day, n = 137), higher calorie (≥1400 kcals/day, n = 154) diets. METHODS: Retrospective chart reviews conducted for patients with known/suspected EDs. INCLUSION: patients ages 12-21 years with anorexia nervosa (AN), bulimia nervosa (BN), eating disorder not otherwise specified (EDNOS), atypical anorexia nervosa (AtAN). EXCLUSION: patients with other EDs, co-morbid medical conditions. Demographic information, length of stay, anthropometrics, prior weight loss were recorded. Malnutrition classifications based on: %mBMI, BMI z-score, prior weight loss percentage. Laboratory data, electrolyte supplementations were collected. Initial calorie intake/calorie intake day 7 were recorded. RESULTS: No significant differences in age, admit weight, BMI, BMI z-score, %mBMI at admission, weight gain between the two groups. Six (4.4%) patients in lower calorie group, 4 (2.6%) in higher calorie group met criteria for severe refeeding syndrome based on ASPEN consensus recommendations (P = .52). Higher calorie group length of stay was significantly shorter than lower calorie group (P = .006). Shorter length of stay associated with increased calorie intake (P < .001), greater %mBMI (P < .001). Higher calorie prescriptions were not associated with different rates of hypomagnesia (P = 1) and hypokalemia (P = .34). There was significant increase in rate of hypophosphatemia in the lower calorie group versus the higher calorie group. CONCLUSION: Higher calorie diets were associated with decreased length of stay without impacting risk of refeeding syndrome.

Factors associated with refeeding hypophosphatemia in adolescents and young adults hospitalized with anorexia nervosa.

BACKGROUND: Refeeding hypophosphatemia (RH) in individuals with anorexia nervosa (AN) is a potentially fatal complication of nutrition restoration; yet, little is known about risk. This retrospective cohort study examined factors found in hospitalized youth with AN that may contribute to RH. METHODS: We reviewed medical records of 300 individuals diagnosed with AN admitted between the years of 2010 and 2016. Logistic regression examined factors associated with RH. Multivariate regression examined factors associated with phosphorus nadir. RESULTS: For 300 participants, the mean (SD) age was 15.5 (2.5) years, 88.3% were White, and 88.3% were female. Participants lost an average of 11.3 (9.7) kg of body weight and were 82% (12.1) of median body mass index (BMI). Age (P = .022), nasogastric (NG) tube feeding (P = .054), weight gain (P = .003), potassium level (P = .001), and magnesium level (P = .024) were contributors to RH. Odds of RH were 13.7 times higher for each unit reduction in magnesium, 9.2 times higher for each unit reduction in potassium, three times higher in those who received NG feeding, 1.5 times higher for each kg of weight gain, and 1.2 times higher for each year of age. Regarding phosphorus nadir, serum magnesium level (P < .001) and admission BMI (P = .002) contributed significantly. CONCLUSION: The results indicate that age, NG feeding, weight gain, electrolyte abnormalities, and BMI on admission are potential indicators of the development of RH in youth. This study identifies clinical risk factors associated with RH and may guide further investigation.

Is the risk of refeeding syndrome a problem in reaching nutritional requirements? A cohort of patients on enteral nutrition support.

INTRODUCTION: Background: refeeding syndrome (RS) is a metabolic complication associated with nutritional support. The lack of management protocols for patients on nutritional support may lead to the development of RS or undernourishment. Objective: to evaluate adherence to the algorithm for total enteral nutritional support (ASNET), and the efficacy of reaching nutrient requirements in patients at risk of RS. Methods: a cohort study: screening and nutritional evaluation of patients and risk of RS were performed. Adults admitted to hospital for noncritical illness who received exclusively enteral nutrition (EN) were eligible. Patients with RS, intestinal failure or chronic diarrhea were excluded. Adherence to ASNET was evaluated along with the efficacy of nutritional support to reach the optimal protein and energy requirement (OPER) and any associated complications. Patient follow-up ended when the feeding route was changed or upon discharge. Results: a total of 73 patients were included (mean age, 62 ± 16 yrs; BMI, 18.5 ± 4.2 kg/m2), and 55 % were men. All had nutritional risk of developing RS (57, low; 15, high; 1, very high); 34 % had adequate adherence to ASNET, and 33 % managed to cover the total requirement between 4 and 6 days. OPER was reached by 38 % by the fourth day of EN, and adequate adherence to ASNET increased the probability of achieving it (RR, 2.2; 95 % CI, 1.6-3.2, p < 0.0001) without increasing the associated complications. Nonetheless, 36 % developed complications, of whom 96 % did not adhere to ASNET. Conclusion: adherence to ASNET in patients at risk of RS allowed the achievement of OPER safely by day four with fewer associated complications.

INTRODUCCIÓN: Antecedentes: el síndrome de realimentación (SR) es una complicación metabólica asociada al soporte nutricional y la falta de protocolos puede conducir a su desarrollo o a desnutrición. Objetivo: evaluar la adherencia al algoritmo de soporte nutricional enteral total (ASNET) y la eficacia de alcanzar los requisitos de nutrientes en pacientes con riesgo de SR. Métodos: se realizó un estudio de cohortes con evaluación nutricional del paciente y del riesgo de SR. Fueron elegibles los adultos ingresados en el hospital por una enfermedad no crítica que recibían exclusivamente nutrición enteral (NE). Se excluyeron los pacientes con SR, falla intestinal o diarrea crónica. Se evaluaron la adherencia al ASNET y la eficacia para alcanzar el requerimiento óptimo de proteína, energía (OPER) y cualquier complicación asociada. El seguimiento finalizó cuando se cambió la ruta de alimentación o al alta. Resultados: se incluyeron 73 pacientes (edad de 62 ± 16 años, IMC de 18,5 ± 4,2 kg/m2) y el 55 % fueron hombres. Todos tenían riesgo nutricional de desarrollar SR (57 bajo; 15 alto; 1 muy alto). El 34 % presentaron una adherencia adecuada y el 33 % lograron cubrir el requerimiento total entre 4 y 6 días. La OPER se alcanzó en el 38 % al cuarto día de NE, y la adecuada adherencia al ASNET aumentó la probabilidad de lograrla (RR: 2.2; IC 95 %: 1,6-3,2, p < 0,0001) sin incrementar las complicaciones asociadas. No obstante, el 36 % desarrollaron complicaciones y el 96 % de estos casos no se habían adherido al ASNET. Conclusión: la adherencia al ASNET en los pacientes con riesgo de SR permitió lograr la OPER de forma segura al cuarto día y con menos complicaciones asociadas.

Refeeding syndrome in surgical patients post initiation of artificial feeding, a prospective cohort study in a low-income country.

BACKGROUND & AIMS: South Africa's inequitable history has contributed to a malnourished population, further aggravated by high levels of violence and economic uncertainty culminating in a population suffering the sequelae of poverty. The perceived notion is that malnutrition places the South African population at greater risk for development of refeeding syndrome. This study aimed to identify the incidence of refeeding syndrome in the South African population. METHODS: All patients admitted into the surgical intensive care unit from 1 November 2019 to 30 September 2020, were screened using the National Institute for Health and Care Excellence (NICE) refeeding risk criteria. Patients started on artificial feeds with one or more risk factors were included in the study. The syndrome was confirmed using the King's College criteria and compared with the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria for refeeding syndrome. RESULTS: 200 Patients were included in this study. The median age of the sample population was 41 years (IQR 30-58) with a male predominance (63%). All patients included had one or more risk factors and 62 (31%) of patients fulfilled the NICE criteria. The sensitivity of the NICE criteria was 33% and specificity was 70%. The most common risk factors identified were little or no nutritional intake for >5 days (55%) followed by a history of alcohol abuse, drugs including insulin, chemotherapy, diuretics or antacids (18%). Specificity values for all risk factors were >80% apart from little or no nutritional intake for >5 days which had a specificity of 64.2%. Sensitivity values for all risk factors were low. 84.5% of patients received artificial nutritional support in the form of enteral feeds, 9% parenteral and 6.5% both enteral and parenteral feeds. A total of 146 patients required electrolyte supplementation. Three patients fulfilled the King's College criteria and one subsequently died. In comparison, 25 patients fulfilled the ASPEN criteria and 3 demised. CONCLUSION: Due to the low sensitivity and specificity of the NICE criteria, we advise that it be used merely as a guideline to identify patients at risk of refeeding syndrome and one should remain vigilant in patients with any risk factors present. Due to the small number of patients who fulfilled the King's College criteria and significant difference in incidence when compared to the ASPEN definition, a conclusion regarding the accuracy of both diagnostic criteria could not be made. We recommend a review of the current definition and a global adoption of an agreed criteria for the estimation of the true prevalence.

A comparison of two different refeeding protocols and its effect on hand grip strength and refeeding syndrome: a randomized controlled clinical trial.

PURPOSE: Optimal refeeding protocols in older malnourished hospital patients remain unclear. We aimed to compare the effect of two different refeeding protocols; an assertive and a cautious protocol, on HGS, mortality and refeeding syndrome (RFS), in patients ≥ 65 years METHODS: Patients admitted under medical or surgical category and at risk of RFS, were randomized to either an enteral nutrition (EN) refeeding protocol of 20 kcal/kg/day, reaching energy goals within 3 days (intervention group), or a protocol of 10 kcal/kg/day, reaching goals within 7 days (control group). Primary outcome was the difference in hand grip strength (HGS) at 3 months follow-up, in an intention to treat analysis. RFS (phosphate < 0.65 mmol/L) during the hospital stay and mortality rates at 3 months were secondary outcomes. RESULTS: A total of 85 patients were enrolled, with mean (SD) age of 79.8(7.4) and 54.1% female, 41 in the intervention group and 44 in the control group. HGS was similar at 3 months with mean change of 0.42 kg (95% CI - 2.52 to 3.36, p = 0.78). Serum phosphate < 0.65 mmol/L was seen in 17.1% in the intervention group and 9.3% in the control group, p = 0.29. There was no difference in mortality rates (39% vs 34.1%, p = 0.64). An indication of more respiratory distress was found in the intervention group, 53.6% vs 30.2%, p = 0.029. CONCLUSION: A more assertive refeeding protocol providing 20 kcal/kg/day did not result in improved HGS measured 3 months after discharge compared with a cautious refeeding (10 kcal/kg/day) protocol. No difference in incidence of mortality or RFS was found. TRIAL REGISTRATION: ClinicalTrials.gov Protocol Record 2017/FO148295, Registered: 21st of February, 2017.

An unexpectedly high incidence of refeeding syndrome in patients with total parenteral nutrition in a reference university hospital.

INTRODUCTION: Refeeding syndrome occurs with the reintroduction of food after an individual has undergone a substantial period of malnutrition. The development of this condition is not uncommon but is neglected in most cases. OBJECTIVE: To identify the incidence of refeeding syndrome in hospitalized patients undergoing total parenteral nutrition and factors that may be associated with this condition. MATERIALS AND METHODS: Observational retrospective and prospective cohort study. Data collection took place at the Hospital de Clínicas de Porto Alegre, from 2015 to 2018. Data was collected consecutively from patient electronic medical records. All hospitalized individuals aged 18 years or more and having a prescription for total parenteral nutrition were included in the study. Exclusion criteria included patients with diabetic ketoacidosis; receiving renal replacement therapy or chronic kidney disease with a glomerular filtration rate <30 mL/min; severe metabolic acidosis or any disease that could affect serum phosphorus levels. WinPepi software, version 11.65, was used to calculate sample size. Data analysis was performed using SPSS version 20.0. A 5% significance level was considered for the established comparisons. The project was approved by the Research Ethics Committee of Hospital de Clínicas de Porto Alegre (number 17-0313). RESULTS: Data from 97 patients was collected. The incidence of refeeding syndrome in our sample was 43.3% (n = 42). Factors positively associated with the syndrome were use of standard parenteral nutrition (p < 0.01), advancing age (mean 62.8 yr versus 55.1 yr; p = 0.013), and amount of total energy administered, which were 25.6 kcal/kg/day versus 23.6 kcal/kg/day for patients with and without refeeding syndrome, respectively (p < 0.01). CONCLUSION: The incidence of refeeding syndrome in individuals using total parenteral nutrition was high. The supply of a greater quantity of total energy in the first week of nutritional therapy, the absence of electrolytes in the parenteral nutrition solution and advancing age were all factors associated with the emergence of refeeding syndrome.

The incidence of the refeeding syndrome. A systematic review and meta-analyses of literature.

BACKGROUND & AIMS: The refeeding syndrome (RFS) has been recognized as a potentially life-threatening metabolic complication of re-nutrition, but the definition widely varies and, its incidence is unknown. The aim of this systematic review and meta-analyses was to estimate the incidence of RFS in adults by considering the definition used by the authors as well as the recent criteria proposed by the American Society of Parenteral and Enteral Nutrition (ASPEN) consensus. Furthermore, the incidence of refeeding hypophosphatemia (RH) was also assessed. METHODS: Four databases were systematically searched until September 2020 for retrieving trials and observational studies. The incidences of RFS and RH were expressed as percentage and reported with 95% confidence intervals (CI). RESULTS: Thirty-five observational studies were included in the analysis. The risk of bias was serious in 16 studies and moderate in the remaining 19. The incidence of RFS varied from 0% to 62% across the studies. No substantial change in the originally reported incidence of RFS was found by applying the ASPEN criteria. Similarly, the incidence of RH ranged between 7% and 62%. In the subgroup analyses, inpatients from Intensive Care Units (ICUs) and those initially fed with >20 kcal/kg/day seemed to have a higher incidence of both RFS (pooled incidence = 44%; 95% CI 36%-52%) and RH (pooled incidence = 27%; 95% CI 21%-34%). However, due to the high heterogeneity of data, summary incidence measures are meaningless. CONCLUSION: The incidence rate of both RFS and RH greatly varied according to the definition used and the population analyzed, being higher in ICU inpatients and in those with increased initial caloric supply. Therefore, a universally accepted definition for RFS, taking different clinical contexts and groups of patients into account, is still needed to better characterize the syndrome and its approach.

Patients with enteral nutrition at risk of refeeding syndrome show electrolyte abnormalities at admission in the Emergency Department.

INTRODUCTION: Introduction: refeeding syndrome (RFS) is a metabolic complication in the initial phase of nutritional therapy (NT). Studies evaluating electrolyte abnormalities among patients at risk for RFS undergoing NT in the Emergency Department (ED) are scarce. Objective: to explore the occurrence of electrolyte abnormalities among patients at risk for RFS with enteral nutrition admitted to the ED. Material and methods: a retrospective cohort study that evaluated 440 adult patients undergoing NT, admitted to the ED of a public tertiary teaching hospital regarding RFS risk. Additional eligibility criteria included nutritional assessment by registered dietitians and at least one dose of an electrolyte (sodium, potassium, magnesium, phosphate, calcium) ordered by physicians. Differences were considered statistically significant at p < 0.05. Results: RFS risk criteria identified 83 (18.9 %) (65.1 % elderly, aged 64.2 ± 11.6 years, 65.1 % male; body mass index, 17.3 ± 3.5 kg/m²) patients at risk, of which 25 (30.1 %) had phosphorus, 48 (57.8 %) magnesium, and 60 (72.3 %) calcium dosages within the first week. All patients at risk for RFS had potassium and sodium evaluations. In those patients were serum levels were checked, hypophosphatemia was identified in 10 (40.0 %), hypomagnesemia in 12 (25.0 %) and hypokalemia in 13 (15.7 %) patients. Almost half of phosphorus assessments resulted from advice by registered dietitians to the staff. Conclusion: electrolyte evaluation was not ordered in all at-risk patients on NT. Despite the small sample, hypophosphatemia was a very common condition among this group. This study highlights the importance of RFS risk screening awareness among NT patients, and the important role of registered dietitians in this context. Larger sample studies are needed to confirm these results.

INTRODUCCIÓN: Introducción: el síndrome de realimentación (SR) es una complicación metabólica de la fase inicial del soporte nutricional (SN). Los estudios que evalúan trastornos electrolíticos en pacientes con riesgo de desarrollar SR y sometidos a NT en el servicio de Urgencias (SU) son escasos. Objetivo: explorar la aparición de trastornos electrolíticos en pacientes con riesgo de desarrollar SR con nutrición enteral, ingresados en Urgencias. Material y método: cohorte retrospectiva que evaluó 440 pacientes adultos con SN ingresados en el SU en cuanto al riesgo de desarrollar SR. Los criterios de elegibilidad fueron una evaluación nutricional por dietistas y al menos una dosis de un electrólito (sodio, potasio, magnesio, fosfato, cálcio) a petición de los médicos. Resultados: se identificaron 83 (18,9 %) pacientes con riesgo (65,1 % ancianos, edad de 64,2 ± 11,6 años, 65,1 % de varones; índice de masa corporal, 17,3 ± 3,5 kg/m²), de los que 25 (30,1 %) habían recibido dosis de fósforo, 48 (57,8 %) magnesio y 60 (72,3 %) calcio. Todos los pacientes tenían evaluaciones de potasio y sodio. Entre los pacientes en los que se midieron niveles séricos, se encontró hipofosfatemia en 10 (40,0 %), hipomagnesemia en 12 (25,0 %) e hipopotasemia en 13 (15,7 %). Aproximadamente, la mitad de las evaluaciones de fósforo se llevaron a cabo por consejo de los nutricionistas al personal médico. Conclusión: no se ordenó la evaluación de electrólitos en todos los pacientes con riesgo de SR en SN. A pesar de la pequeña muestra, la hipofosfatemia fue una condición muy común en este grupo. Este estudio destaca la importancia de la concienciación sobre el cribado del riesgo de SR en los pacientes con SN y el importante papel de los nutricionistas en este contexto. Se necesitan estudios con muestras grandes para confirmar estos resultados.

Incidence of Refeeding Syndrome in Pediatric Inpatients at the US-Mexico Border.

OBJECTIVES: Refeeding syndrome is a life-threatening, physiological process that occurs when patients with severe malnutrition are too rapidly rehabilitated, leading to the development of electrolyte abnormalities. Hypophosphatemia, a hallmark of the disease, has most commonly been studied, because it is recognized to result in cardiac arrhythmias, seizures, cardiac failure, respiratory failure, rhabdomyolysis, coma, and even death. Although many studies have found caloric intake to be a main causal factor in refeeding syndrome, few have explored other factors, such as geographic location. Border cities, such as El Paso, Texas, have a unique, diverse population. The purpose of this study was to establish the incidence of refeeding syndrome concentrated within a border city. METHODS: We performed a retrospective chart review that focused on the incidence of refeeding syndrome in pediatric patients with eating disorders, ages 10 to 19 years, admitted to El Paso Children's Hospital, the only tertiary teaching hospital in the area, associated with Texas Tech University Health Science Center, located along the US-Mexico border, in El Paso, Texas. RESULTS: Twenty-six subjects with a diagnosis of eating disorder were admitted to El Paso Children's Hospital for treatment between 2012 and 2019. Five subjects developed refeeding syndrome, recognized in our study as hypokalemia or hypomagnesemia, during their treatment. CONCLUSIONS: Among hospitalized adolescents admitted to El Paso Children's Hospital, 19% developed refeeding syndrome. This incidence was higher in our population than had been previously reported. Further research is needed to better establish a protocol for the treatment of patients with eating disorders.

[Refeeding syndrome]. / Syndrome de renutrition inappropriée.

Refeeding syndrome (RS) is a rare but severe condition that is poorly understood, often under-diagnosed and can lead to death. It occurs within 5 days after refeeding in patients after prolonged fasting or in a context of undernutrition. As a consequence of the abrupt transition from catabolism to anabolism, RS is defined as a decrease in plasma levels of phosphorus, potassium and/or magnesium, whether or not associated with organ dysfunction resulting from a decrease in one of the electrolytes or a thiamine deficiency, after refeeding. The clinical symptoms are varied and non-specific and are related to hydro electrolyte disorders, sodium-hydroxide retention or failure of one or more organs. Patient management should be appropriate with regular clinical examination and careful biological monitoring, including hydro electrolyte monitoring. The correction of hydroelectrolytic disorders and systematic thiamine supplementation are essential during refeeding, that must be done carefully and very progressively, whatever its form (oral, enteral or parenteral). The severity of the refeeding syndrome indicates that its prevention and screening are the corners of its management in at-risk patients.