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INTRODUCTION: Undernourishment is a common health problem among elderly individuals, and its prevalence grows among frail patients, which makes nutritional support a priority, especially in acute diseases. However, providing nutritional support to undernourished patients or to those under acute caloric deprivation may lead to electrolyte disturbances associated with neurological, respiratory, and cardiac symptoms, including cardiac arrest. These disturbances occur a few days after receiving nutritional support, and characterize the refeeding syndrome. METHODOLOGY: Five elderly patients hospitalized for clinical reasons and who developed refeeding syndrome during the duration of the stay, were retrospectively evaluated. RESULTS: All patients analyzed were malnourished and frail, of whom four were women. The age group ranged between 82 and 85 years, and food deprivation time ranged between 7 to 15 days. Three patients had severe dementia and were admitted with hypoactive delirium. Hypophosphatemia occurred in 100% of the sample, followed by hypokalemia (60%) and hypomagnesemia (40%). Four patients developed peripheral edema, two developed metabolic ileus and three elderly persons (who had lower phosphorus values) died during the hospital stay. CONCLUSION: All refeeding syndrome patients developed hypophosphatemia, with fatal outcome among those whose phosphorus values were lower. The development of peripheral edema and metabolic ileus was frequent. Owing to the lack of data in literature, new researches on refeeding syndrome are extremely important. Electrolyte evaluation before and after nutritional support in patients at risk, is indispensable to facilitate recognition and treatment of this severe condition.

Abstract Hypophosphatemia (serum phosphate

Trichobezoar with Rapunzel syndrome is a rare condition seen in young females. Refeeding syndrome is a rare phenomenon that can occur in any chronically malnourished person after starting feeds. We discuss and review available literature of extremely rare cases of 11-year-old girl, with trichobezoar with refeeding syndrome with subacute intestinal obstruction in the postoperative period.

Refeeding syndrome is a serious complication of malnutrition that occurs when someone who has been starved begins feeding again. Due to the lack of specificity, it is difficult to distinguish and the incidence is relatively high. Patients with severe acute pancreatitis are vulnerable to refeeding syndrome as high level of metabolism caused by serious condition or infection. Current researches mainly focus on pathogenesis, risk factors, prevention and nursing care of the refeeding syndrome. Because of the complexity and variation of clinical manifestations and weak specificity, the clinical practice of patients with refeeding syndrome is still controversial. This paper reviews studies on concept, current research status, pathogenesis, risk factors and other issues of refeeding syndrome in patients with severe acute pancreatitis, and puts forward suggestions for clinical practice, in order to provide reference for clinical diagnosis, prevention and treatment of refeeding syndrome. (再喂养综合征(RFS)是长期营养不良患者重新摄入营养初期机体代谢异常所导致的一系列代谢紊乱症候群, 由于缺乏特异性, 不易辨别, 发生率较高。重症急性胰腺炎患者因病情危重、感染等原因, 机体处于高分解、高代谢状态, 发生RFS风险较高。目前国内外关于RFS的研究, 涉及发病机制、危险因素、预防及护理等多方面, 但由于RFS的临床症状复杂多样且缺乏特异性, 易被临床医护人员忽视, 且具体护理措施仍然存在争议。本文通过对再喂养综合征定义、国内外现状、发生机制、危险因素等进行综述, 并提出护理建议, 以期为医护人员观察、识别和预防RFS提供参考依据。)

Abstract Background Refeeding syndrome is the gravest possible medical complication in malnourished patients undergoing refeeding in the hospital. We previously reported that males with malnutrition secondary to eating disorders required more calories and had longer hospital stays than females; however, sex differences in electrolyte abnormalities indicating refeeding syndrome risk remain unknown. The objective of this study was to assess differences in electrolyte abnormalities indicating refeeding syndrome risk among male and female adolescents and young adults with eating disorders hospitalized for medical instability. Methods We retrospectively reviewed the electronic medical records of 558 patients aged 9–25 years admitted to the University of California, San Francisco Eating Disorders Program for medical instability between May 2012 and August 2020. Serum was drawn per standard of care between 5 and 7 am each morning and electrolyte abnormalities indicating refeeding syndrome risk were defined as: hypophosphatemia (

BACKGROUND: Refeeding syndrome (RFS) is a potentially serious complication that can occur during the reintroduction of nutrition in individuals who have experienced a period of malnutrition or starvation. The pathophysiology of RFS is multifaceted and primarily driven by shifts in electrolytes, fluids, and metabolic substrates, including phosphate, potassium and magnesium, as well as thiamine deficiency. RFS can be easily overlooked due to the wide range of clinical presentations, from asymptomatic electrolyte disturbance to multiorgan failure. It is vital to recognize the condition to identify at-risk patients and implement preventive measures. OBJECTIVES: This review article aims to increase awareness of refeeding syndrome, educate physicians and other healthcare professionals, especially those outside of nutrition support teams, and provide a concise overview of the existing knowledge and suggested guidelines regarding RFS. CONCLUSIONS: Although refeeding syndrome is potentially fatal, its occurrence is preventable. During the initial 2-5 days of increased calorie intake, it is crucial to monitor the concentrations of phosphate and other electrolytes, as well as to check for any new symptoms. The key components of RFS therapy include slow increases in feeding rates, phosphate and potassium replacement, fluid management, and thiamine supplementation. Further research is required on refeeding syndrome, including epidemiological studies, investigations into pathophysiology such as the role of magnesium, and large-scale randomized controlled clinical trials to establish a consensus on management.

“Refeeding syndrome” is described in the literature as a range of metabolic and electrolyte disorders that result from starting nutritional rehabilitation in malnourished patients. Without a universally accepted definition, data on “refeeding syndrome” incidence are heterogeneous. In most cases, a clinician will subjectively identify “refeeding syndrome,” many authors have developed their purposes and criteria for it in their studies. Using the PubMed database and the appropriate filters (“refeeding syndrome”-related terms: refeeding syndrome, pediatrics, child, nutrition support, nutrition assessment, malnutrition), a search of the published literature was conducted. The American Society for Parenteral and Enteral Nutrition’s 2020 recommendations are the only guidelines for identifying children with or at risk for “refeeding syndrome”. High-quality scientific evidence regarding the clinical syndrome is absent, so we need further research in all “refeeding syndrome”-related areas, from validation to better identification of risk factors, definitions of “refeeding syndrome,” and standardization of treatment protocols. For now, clinicians must remain vigilant to protect patients from the potentially devastating consequences of the “refeeding syndrome.”

Abstract Background Refeeding hypophosphatemia (RH) is a common complication of nutritional restoration in malnourished individuals, yet clear risk stratification remains elusive. Individuals with anorexia nervosa (AN) and avoidant/restrictive food intake disorder (ARFID) may be deficient in vitamin D, an important component of dietary phosphorus absorption in the gut. The relationship between vitamin D and RH in AN and ARFID is unknown. Therefore, the aims of this study were to (1) report rates of low serum 25-hydroxy vitamin D and RH in AN and ARFID; (2) describe associations between phosphorus and variables associated with RH identified in extant literature; (3) examine the relationship between 25-hydroxy vitamin D and RH and (4) investigate moderation by vitamin D between variables of interest and phosphorus level. Method Analyses included retrospective chart review of 307 individuals admitted to the ACUTE Center for Eating Disorders and Severe Malnutrition with a diagnosis of AN or ARFID. Variables of interest included admission laboratory values (vitamin D level, comprehensive metabolic panel, hemoglobin, point-of-care blood glucose), anthropometric measures (weight, body mass index [BMI], % ideal body weight [IBW]), age, duration of illness, length of stay, feeding method, and serum phosphorus nadir. Pearson and Spearman rank correlation, one-way ANOVA, and regression analyses were used to determine the relationship between variables and serum phosphorus. Results Over 1/3 of the sample (35.3%) had serum phosphorus levels ≤ 2.9 mg/dL. There were no significant differences between groups in phosphorus nadir (p = .17, η 2 = 0.12) or hypophosphatemia (p = .16, ϕc = 0.11). Thirty-five (35%) of individuals with ARFID were either deficient or insufficient in vitamin D, compared to 29% of individuals with AN. Individuals with AN had significantly higher mean vitamin D levels compared to those with ARFID (p = .03; η 2 = 0.015). Nadir phosphorus showed a positive association with weight, BMI, %IBW, potassium, and calcium on admission, and a negative association with length of stay, hemoglobin, and total number of tube-fed days. Higher levels of 25-hydroxy vitamin D moderated the relationship between serum phosphorus nadir and weight on admission (p = .0004). Conclusion Individuals diagnosed with ARFID are as nutritionally fragile as those with AN regarding vitamin D and RH. The negative feedback loop involving vitamin D that maintains phosphorus homeostasis may play a role in the development of RH in AN and ARFID.

Shortly after weaning, piglets generally eat dry feed poorly; but nevertheless, a phenomenal gain-to-feed ratio is achieved as they gain about as much weight as they eat (150–200 g/d). The high gain-to-feed ratio, though, cannot be explained by their nutrient intake or nutrient repartitioning. Analyses based on tissue composition and bio-electrical impedance data showed that newly weaned piglets lose fat, maintain protein, and gain large amounts of water because of edema. This edema, which may well contribute up to one kg of BW, seems to be triggered by refeeding syndrome. Refeeding syndrome in adult humans occurs when subjects fast for an extended period of time (weeks) that results in downshifts in metabolic activity and concomitant shedding of phosphate (PO4), magnesium (Mg), and potassium (K) in urine. If food is abruptly reintroduced, thus, resulting in strong insulin spikes, metabolism is triggered but hampered by a lack of PO4, Mg, K, and thiamine, causing hypophosphatemia, metabolic stress, and edema. In piglets, the same process appears to happen immediately after weaning but in hours rather than weeks, possibly linked to their high metabolic rate. Refeeding syndrome can be lethal in humans but does not appear to be directly lethal in piglets. Our attempts to prevent it through altered diet composition and/or controlled feeding programs have not resulted in better performance at the end of the nursery phase. A practical ramification of weaning-induced edema is that growth and gain-to-feed ratio data immediately after weaning should be interpreted with caution. In addition, diets arguably should be formulated to not strongly trigger insulin release, while high lysine levels are not needed as the gain is not based on protein accretion.

Refeeding syndrome (RFS) refers to the clinical syndrome caused by intracellular and extracellular transfer of the body fluids and electrolytes in patients with long-term malnutrition or fasting during the initial stage of active nutritional therapy (enteral, parenteral, or oral). In 2020, the American Society for Parenteral and Enteral Nutrition (ASPEN) defines RFS as a range of metabolic and electrolyte alterations that occur after refeeding. RFS can present as mild RFS only with electrolyte disturbances and few clinical symptoms, or as severe RFS with circulatory and respiratory failure. The clinical manifestations of RFS are diverse and non-specific, which are easy to be ignored by clinicians. The incidence of RFS is 0-80%, which varies with the population and the definition of RFS. The diagnostic criteria for RFS have always been highly heterogeneous, ranging from simple hypophosphatemia to severe low serum electrolyte levels accompanied by fluid imbalance and/or organ dysfunction. The high-risk factors for RFS include patients with anorexia nervosa, patients with mental disorders, and alcohol or drug abusers. The occurrence of RFS in critically ill patients is associated with high mortality rates, ranging from 52.3% to 83.3%.At present, before nutritional treatment, the screening of patients with high risk to develop refeeding problem is mainly based on the National Institute for Health and Care Excellence (NICE) criteria in 2006, but its effectiveness needs to be improved. Therefore, it is necessary to screen and identify high-risk patients early to avoid severe electrolyte disturbance and deterioration of clinical symptoms, thus reduce the risk of death.

Objective:One of the most important issues to be considered in patients who are started on nutritional therapy is refeeding syndrome (RS), which can occur within the first four days. Hypophosphatemia (serum phosphorus level

Abstract Background Nutritional rehabilitation for patients with anorexia nervosa involves balancing the need for weight gain whilst mitigating the risk of refeeding syndrome. Graded caloric increases and restriction of calories from carbohydrate have been used to minimise the risk of developing refeeding hypophosphatemia. There is little evidence to support the recommended nutrient composition, specifically the recommended carbohydrate intake that is safe in this population. The aim of this pilot study was to compare the effect of a low and a standard carbohydrate feeding protocol on serum phosphate levels in children and adolescents with anorexia nervosa. Methods A pilot study of 23 children and adolescents with anorexia nervosa admitted for medical stabilisation to the adolescent ward of a tertiary hospital was undertaken. Participants were commenced on an oral feeding protocol and were randomly allocated to isocaloric meal plans that were either low carbohydrate (

BackgroundThe incidence of refeeding syndrome (RFS) in critically ill patients is high, which is detrimental to their prognoses. However, the current status and risk factors for the occurrence of RFS in neurocritical patients remain unclear. Elucidating these aspects may provide a theoretical basis for screening populations at high risk of RFS.MethodsA total of 357 patients from January 2021 to May 2022 in a neurosurgery ICU of a tertiary hospital in China were included using convenience sampling. Patients were divided into RFS and non-RFS groups, based on the occurrence of refeeding-associated hypophosphatemia. Risk factors for RFS were determined using univariate and logistic regression analyses, and a risk prediction model for RFS in neurocritical patients was developed. The Hosmer-Lemeshow test was used to determine the goodness of fit of the model, and the receiver operator characteristic curve was used to examine its discriminant validity.ResultsThe incidence of RFS in neurocritical patients receiving enteral nutrition was 28.57%. Logistic regression analyses showed that history of alcoholism, fasting hours, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, Sequential Organ Failure Assessment (SOFA) scores, low serum albumin, and low baseline serum potassium were risk factors of RFS in neurocritical patients (p

We present the case of a 66-year-old man with no abdominal symptoms other than chronic refractory diarrhea. Other causes for diarrhea were excluded. The positive results of anti-SSA antibodies, Schirmer’s test, and the biopsy of minor salivary glands confirmed the diagnosis of Sjogren’s syndrome. Moreover, during the course of treatment, the patient developed refeeding syndrome. His diarrhea and nutrition resolved with initiation of glucocorticoids. This case highlights that chronic refractory diarrhea can be the chief complaint and most severe symptom in patients with Sjogren’s syndrome.

Plain English Summary Patients hospitalised with anorexia nervosa require nutrition support as part of their treatment, whilst refeeding complications are prevented. Of particular concern, is the reintroduction of carbohydrate to malnourished patients, which has been proposed to cause a surge in insulin levels and disturbance in electrolytes, particularly a decrease in blood phosphate levels. This double-blinded randomised controlled trial measured the occurrence of low phosphate blood levels and other refeeding complications, in adolescent and young adult patients hospitalised with anorexia nervosa. These patients were provided either a lower carbohydrate/high fat feed (28% carbohydrate, 56% fat) or a standard enteral feed (54% carbohydrate, 29% fat). Fewer patients in the lower carbohydrate/high fat feed group (5/14) than standard feed group (9/10) developed a low phosphate level. There was no significant difference in weight gain, number of days to reach medical stability, occurrence of hypoglycaemia, or hospital length of stay.

Abstract The preferential use of the oral/enteral route in critically ill patients over gut rest is uniformly recommended and applied. This article provides practical guidance on enteral nutrition in compliance with recent American and European guidelines. Low-dose enteral nutrition can be safely started within 48 h after admission, even during treatment with small or moderate doses of vasopressor agents. A percutaneous access should be used when enteral nutrition is anticipated for ≥ 4 weeks. Energy delivery should not be calculated to match energy expenditure before day 4–7, and the use of energy-dense formulas can be restricted to cases of inability to tolerate full-volume isocaloric enteral nutrition or to patients who require fluid restriction. Low-dose protein (max 0.8 g/kg/day) can be provided during the early phase of critical illness, while a protein target of > 1.2 g/kg/day could be considered during the rehabilitation phase. The occurrence of refeeding syndrome should be assessed by daily measurement of plasma phosphate, and a phosphate drop of 30% should be managed by reduction of enteral feeding rate and high-dose thiamine. Vomiting and increased gastric residual volume may indicate gastric intolerance, while sudden abdominal pain, distension, gastrointestinal paralysis, or rising abdominal pressure may indicate lower gastrointestinal intolerance.

Head and neck squamous cell cancer (HNSCC) involves cancer of the oral cavity, oropharynx, hypopharynx and larynx. By virtue of the tumour location, nutrition support in this patient cohort can be extremely challenging. A 48-year-old male presented with a two-month history of progressive dysphagia, significant loss of weight, shortness of breath and coughing secondary to a non-benign lesion in his throat. This debilitating condition led to severe malnutrition and due to the prevailing nutritional risk the patient was assessed as a very high risk for refeeding syndrome. Several investigations were done during the admission, which then confirmed the final diagnosis of a transglottic squamous cell cancer. Surgical optimisation, including preoperative nutritional optimisation, was discussed in a multidisciplinary meeting and a total laryngectomy was scheduled seven days later. Perioperative nutritional management required careful consideration of several factors but the involvement of dietetics services from the day of admission played a crucial role in the successful management of this patient.

Resumen: Introducción: La nutrición parenteral agresiva con aportes energéticos y proteicos altos se utiliza para mejorar el crecimiento y el neurodesarrollo en recién nacidos prematuros de muy bajo peso. No obstante, hallazgos recientes sugieren que su uso puede ocasionar alteraciones electrolíticas. El objetivo del estudio era comparar la prevalencia de hipercalcemia, hipofosfatemia e hipopotasemia en dos grupos de recién nacidos prematuros que recibieron nutrición parenteral con distintos aportes de aminoácidos y analizar variables perinatales y nutricionales asociadas a la ocurrencia de alteraciones electrolíticas. Métodos: Estudio retrospectivo observacional, con comparación de dos grupos de recién nacidos prematuros con peso < 1.500 g y edad gestacional < 33 semanas, que recibían nutrición parenteral. Uno de los grupos recibió < 3 g/kg/d de aminoácidos, mientras que el otro recibió ≥ 3 g/kg/d. Se analizó la prevalencia de distintas alteraciones electrolíticas y su asociación con la nutrición parenteral agresiva, con ajustes para posibles factores de confusión. Resultados: El análisis incluyó 114 recién nacidos: 60 que recibieron < 3 g/kg/d de aminoácidos (bajo aporte) y 54 que recibieron ≥ 3 g/kg/d (alto aporte). La prevalencia de alteraciones electrolíticas fue similar en ambos grupos. La prevalencia de hipercalcemia fue de 1,67% en el grupo de bajo aporte y 1,85% en el grupo de alto aporte (p > 0,99). Los respectivos valores para las otras alteraciones fueron 11,7 vs. 9,3% en el caso de la hipofosfatemia grave y 15,0 vs. 11,1% en el caso de la hipopotasemia (p > 0,99). Se observó que una relación calcio:fósforo superior a 1,05 mostraba un efecto protector frente a la hipofosfatemia (p = 0,007). Conclusiones: No se observó asociación entre la hipercalcemia, hipofosfatemia o la hipopotasemia y el aporte de aminoácidos mediante nutrición parenteral en la población de recién nacidos prematuros con altos aportes de aminoácidos. Abstract: Introduction: Aggressive parenteral nutrition with delivery of high amino acid and energy doses is used to improve growth and neurodevelopmental outcomes in very low birth weight (VLBW) preterm infants. Recent findings, however, suggest that this approach may cause electrolyte imbalances. The aim of our study was to compare the prevalence of hypercalcaemia, hypophosphataemia, and hypokalaemia in 2 groups of preterm infants that received parenteral nutrition with different amounts of amino acids and to analyse perinatal and nutritional variables associated with the development of electrolyte imbalances. Methods: We conducted a retrospective observational study comparing 2 groups of preterm infants born before 33 weeks’ gestation with birth weights of less than 1,500 g managed with parenteral nutrition. One of the groups received less than 3 g/kg/day of amino acids and the other received 3 g/kg/day of amino acids or more. We analysed the prevalence of electrolyte imbalances and possible associations with aggressive parenteral nutrition, adjusting for potential confounders. Results: We studied 114 infants: 60 given less than 3 g/kg/day of amino acids (low-intake group) and 54 given at least 3 g/kg/day (high-intake group). The prevalence of electrolyte imbalances was similar in both groups. The prevalence of hypercalcaemia was 1.67% in the low-intake group and 1.85% in the high-intake group (p > .99), the prevalence of severe hypophosphataemia 11.7 vs. 9.3%, and the prevalence of hypokalaemia 15.0 vs. 11.1% (p > .99). A calcium to phosphorus ratio greater than 1.05 had a protective effect against hypophosphataemia (p = .007). Conclusions: We did not find any association between hypercalcemia, hypophosphatemia, and hypokalemia and amino acid intake by PN in the population of premature infants with quite high amino acid intake values.

Abstract Background Hyperemesis gravidarum (HG) is a common complication during pregnancy, however, HG associated simultaneous onset of blood cell destruction due to electrolyte abnormalities is rare. In this case, a woman with refeeding syndrome (RFS) secondary to electrolyte abnormalities caused by severe HG was diagnosed and managed in our hospital. Case presentation A 29-year old woman was sent to the local hospitals because of severe HG with appetite loss, weight reduction, general fatigue, and she was identified to have severe electrolyte abnormalities. However, the electrolyte abnormalities were not corrected promptly, and then she had the symptoms of stillbirth, altered mental status, visual hallucination, hemolytic anemia and thrombocytopenia. After transferred to our hospital, we continued to correct the electrolyte abnormalities and the labor induction was performed as soon as possible. The symptoms of blood cell destruction were relieved obviously, and the patient discharged four days later. The electrolyte disturbances and physio-metabolic abnormalities caused by HG helped us diagnose this case as RFS. Conclusions This case emphasizes that patients with RFS should be diagnosed appropriately and intervened promptly in order to prevent electrolyte imbalance induced blood cell destruction.

Abstract Distal renal tubular acidosis is a risk factor for refeeding syndrome. Frequent measurement of serum phosphorus levels at the initiation of nutrition and rapid administration of phosphate preparations are required to prevent organ failure.

Background/AimsRefeeding syndrome (RFS) is a fatal clinical complication that can occur as a result of fluid and electrolyte shifts during early nutritional rehabilitation for malnourished patients. This study was conducted to determine the clinical implications of RFS in patients with acute pancreatitis (AP).Methods : Between 2006 and 2016, AP patients with very early mortality were retrospectively enrolled from three university hospitals.Results : Among 3,206 patients with AP, 44 patients died within 3 days after diagnosis. The median age was 52.5 years (range, 27 to 92 years), male-to-female ratio was 3:1, and median duration from admission to death was 33 hours (range, 5 to 72 hours). The etiology of AP was alcohol abuse in 32 patients, gallstones in five patients, and hypertriglyceridemia in two patients. Ranson score, bedside index for severity of AP, and acute physiology and chronic health evaluation-II were valuable for predicting very early mortality (median, [range]; 5 [1 to 8], 3 [0 to 5], and 19 [4 to 45]). RFS was diagnosed in nine patients who died of septic shock (n=5), cardiogenic shock (n=2), or cardiac arrhythmia (n=2). In addition, patients with RFS had significant hypophosphatemia compared to non-RFS patients (2.6 mg/dL [1.3 to 5.1] vs 5.8 mg/dL [0.8 to 15.5]; p=0.001). The early AP-related mortality rate within 3 days was approximately 1.4%, and RFS occurred in 20.5% of these patients following sudden nutritional support.Conclusion : sThe findings of current study emphasize that clinicians should be aware of the possibility of RFS in malnourished AP patients with electrolyte imbalances.

Emilie Aubry,1 Natalie Friedli,2 Philipp Schuetz,2 Zeno Stanga1 1Department for Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Bern, Switzerland; 2Medical University Department, Clinic for Endocrinology, Diabetes, Metabolism and Clinical Nutrition, Kantonsspital Aarau, and Medical Faculty of the University of Basel, Basel, Switzerland Abstract: Aging is linked to physiological and pathophysiological changes. In this context, elderly patients often are frail, which strongly correlates with negative health outcomes and disability. Elderly patients are often malnourished, which again is an independent risk factor for both frailty and adverse clinical outcomes. Malnutrition and resulting frailty can be prevented by adequate nutritional interventions. Yet, use of nutritional therapy can also have negative consequences, including a potentially life-threatening metabolic alteration called refeeding syndrome (RFS) in high-risk patients. RFS is characterized by severe electrolyte shifts (mainly hypophosphatemia, hypomagnesemia and hypokalemia), vitamin deficiency (mainly thiamine), fluid overload and salt retention leading to organ dysfunction and cardiac arrhythmias. Although the awareness of malnutrition among elderly people is well established, the risk of RFS is often neglected, especially in the frail elderly population. This partly relates to the unspecific clinical presentation and laboratory changes in the geriatric population. The aim of this review is to summarize recently published recommendations for the management of RFS based on current evidence from clinical studies adapted with a focus on elderly patients. Keywords: refeeding syndrome, frail, elderly, management, malnutrition

Background and Objective: Refeeding syndrome (RFS) is comprised of severe electrolyte disturbances and metabolic abnormalities that occur after the reinstitution of nutrition to starved patients. Materials and Methods: This prospective study was conducted on patients aged over 18 years who were admitted to the Intensive Care Unit (ICU) of Taleghani and Emam hospitals in Urmia, Iran, during the first half of 2017. The included participants had the ICU stay of more than 48 h, were kept on nil per os, and were under nutritional support. The patients’ serum levels of phosphorus, magnesium, and potassium were measured on the 1st, 3rd, and 7th days of hospital stay. The frequency of RFS, hypophosphatemia, hypomagnesemia, hypokalemia, and the short-term outcomes of patients were obtained and compared. The patients with acute and chronic renal failure, cancer, previous gastrointestinal and hepatic diseases, and electrolyte disorder were excluded from the study. Results: The mean length of ICU stay and duration of mechanical ventilation were 35 and 28.5 days, respectively. The frequency of mortality among the patients was 36.96% (n=95). Furthermore, RFS, hypophosphatemia, hypokalemia, and hypomagnesemia had the frequencies of 13.23%, 25.7%, 21.4%, and 37.7%, respectively. There were significant differences between the patients with RFS and those without RFS in terms of the body mass index, duration of mechanical ventilation, ICU length of stay, and mortality (P

Abstract Background Refeeding syndrome is a rare and life-threatening pathology with polyvisceral manifestations occurring in severely malnourished patients. It is rarely described in adults with celiac disease. Case presentation We report the case of a 28-year-old Tunisian woman followed up for celiac disease, who did not adhere to the gluten-free diet. She presented to our hospital with celiac crisis manifested by severe diarrhea, and metabolic and electrolyte disturbances. The treatment of electrolyte abnormalities, hydration, and nutritional support was marked by the occurrence on the fifth day of refeeding syndrome with psychomotor agitation followed by respiratory distress and a state of cardiogenic shock. Conclusions Refeeding syndrome is still under-recognized. It should be systematically prevented for high-risk patients. Nutritional support in patients with celiac crisis should be monitored carefully since the risk of refeeding syndrome is very high with a poor prognosis.

Refeeding syndrome is an uncommon but potentially fatal condition. It occurs in a patient who consumes a large amount of calories over a brief period of time after a sustained period of starvation. This syndrome is characterized by a high risk of cardiovascular collapse secondary to electrolyte imbalance if left untreated or if there is a delay in the management. Psychiatric patients with a diagnosis of schizophrenia or severe depression are known to refuse food for a prolonged period of time, thus creating a malnourished or starved metabolic state. The purpose of this article is to bring an acute awareness and sensitize the fellow psychiatrists about refeeding syndrome, a likely fatal possibility in a starved or malnourished patient on refeeding. Prompt recognition and management in collaboration with medical colleagues can save the life of these patients.

Refeeding syndrome (RFS) can be defined as a condition with severe electrolyte disturbance and metabolic abnormalities in undernourished patients who are undergoing refeeding. It is a life-threatening condition if not recognized or managed properly. Although there are no universally agreed guidelines on managing RFS, being aware of high-risk groups with close monitoring and a multidisciplinary approach is crucial for prevention as well as management. It is of paramount importance that clinicians are made more aware of this preventable, yet fatal, syndrome. There is also a great need for more randomized controlled trials to be performed, which can guide the clinical practice.

Severe accidental hypothermia has been demonstrated to affect ventricular systolic and diastolic functions, and rewarming might be responsible of cardiovascular collapse. Until now, there have been only a few reports on severe accidental hypothermia, none of which involved children. Herein, we describe here a rare case of heart failure in a 6-year-old boy admitted to the emergency unit owing to severe hypothermia and malnutrition. After he was warmed up (core temperature of 27.2°C at admission), he developed cardiac arrest, requiring vasoactive amines administration, and veno-arterial extracorporeal membrane oxygenation. Malnutrition and refeeding syndrome might have caused the thiamine deficiency, commonly known as beriberi, which contributed to heart failure as well. He showed remarkable improvement in heart failure symptoms after thiamine supplementation. High-dose supplementation per os (500 mg/day) after reconstitution of an adequate electrolyte balance enabled the patient to recover completely within 2 weeks, even if a mild diastolic cardiac dysfunction persisted longer. In conclusion, we describe an original pediatric case of heart failure due to overlap of severe accidental hypothermia with rewarming, malnutrition, and refeeding syndrome with thiamine deficiency, which are rare independent causes of cardiac dysfunction. The possibility of beriberi as a cause of heart failure and adequate thiamine supplementation should be considered in all high-risk patients, especially those with malnutrition. Refeeding syndrome requires careful management, including gradual electrolyte imbalance correction and administration of a thiamine loading dose to prevent or correct refeeding-induced thiamine deficiency.

Refeeding Syndrome is a syndrome which occurs as a result of food administration in poorly nourished individuals. In this syndrome, there are wide range of biochemical alterations, clinical manifestations, and complications, starting from mild (asymptomatic) to severe (death). This syndrome was initially proposed in 1950s; however, there is still no agreement for its clear definition, causing clinicians to be less aware and tend to overlook this condition. Clinical manifestations which usually appear include electrolyte imbalances (hypophosphatemia, hypokalemia, hyponatremia, hypomagnesemia) and vitamin B1 deficiency. The main principle in management of refeeding syndrome is prevention, where clinicians need to identify this condition in the early stage in high risk individuals, supervision during refeeding, and administration of appropriate diet.

Background: Refeeding syndrome (RFS) is an important and well-known complication in malnourished patients, but the incidence of RFS after obesity surgery is unknown and the awareness of RFS in obese patients as a postsurgical complication must be raised. We present a case of RFS subsequent to biliopancreatic diversion in a morbidly obese patient. Case Report: A 48-year-old female patient with a BMI of 41.5 kg/m2 was transferred to our hospital due to Wernicke‘s Encephalopathy in a global malabsorptive syndrome after biliopancreatic diversion. Parenteral nutrition, vitamin supplementation and high-dosed intravenous thiamine supplementation were initiated. After 14 days, the patient started to develop acute respiratory failure, and neurological functions were impaired. Blood values showed significant electrolyte disturbances. RFS was diagnosed and managed according to the NICE guidelines. After 14 days, phosphate levels had returned to normal range, and neurological symptoms were improved. Conclusion: Extreme weight loss following obesity surgery has been shown to be associated with undernutrition. These patients are at high risk for evolving RFS, even though they may still be obese. Awareness of RFS as a postsurgical complication, the identification of patients at risk as well as prevention and correct management should be routinely performed at every bariatric center.

Central pontine myelinolysis (CPM), which was originally considered to be the result of rapid correction of chronic hyponatremia, is not necessarily accompanied by hyponatremia or drastic changes in serum sodium level. Here, we report a case of an anorexic 55-year-old male with a history of pharyngo-laryngo-esophagogastrectomy, initially hospitalized with status epilepticus. Although his consciousness gradually recovered as we were controlling his convulsion, it deteriorated again with new onset of anisocoria, and magnetic resonance imaging (MRI) at this point revealed CPM. Rapid change of serum sodium or osmolarity, which is often associated with CPM, had not been apparent throughout his hospitalization. Instead, a review of the serum biochemistry test results showed that serum phosphate had drastically declined the day before the MRI first detected CPM. In this case, we suspect that hypophosphatemia induced by refeeding syndrome greatly contributed to the occurrence of CPM.

Refeeding syndrome is defined as electrolyte and fluid abnormalities that occur in significantly malnourished patients when they are refed orally, enterally, or parenterally. The principal manifestations include hypophosphatemia, hypokalemia, vitamin deficiencies, volume overload and edema. This can affect multiple organ systems, such as the cardiovascular, pulmonary, or neurological systems, secondary to the above-mentioned abnormalities. Rarely, patients may develop gastrointestinal symptoms and show abnormal liver function test results. We report the case of a 52-year-old woman with anorexia nervosa who developed refeeding syndrome and simultaneous elevations of liver function test results, which normalized upon the resolution of the refeeding syndrome.

Refeeding syndrome is a rare but preventable complication of malnutrition management. This is the second case of refeeding syndrome being reported from Pakistan. Although many cases have been reported worldwide. It is a clear indication of lack of knowledge of the entity (Refeeding syndrome) in our doctor’s community. Refeeding syndrome presents with a mix picture of clinical manifestations and thus it is necessary to keep a regular check and balance of electrolyte disturbance especially serum phosphate levels before and after initiating nutrition irrespective of the route nutrition are given through. We are reporting a case of refeeding syndrome in a severely malnourished 5-year-old child which unfortunately died despite taking strict lifesaving actions.

A severely chronically protein and calorie restricted young woman with argininosuccinate lyase deficiency developed transient refeeding syndrome (RFS) and hyperammonemia after modest diet liberalization following initiation of glycerol phenylbutyrate (GPB). The patient required IV supportive care and supplementation with potassium, magnesium and calcium. She is now doing well on GPB and an appropriate maintenance diet. Susceptibility to RFS should be considered in chronically nutritionally restricted patients with metabolic disorders after liberalization of diet.

Disease-associated malnutrition, also defined as cachexia, is a complex syndrome characterised by the progressive deterioration of nutritional status resulting from the combined effects of reduced appetite and food intake, and profound changes in host metabolism. Cachexia has been repeatedly demonstrated to represent a negative prognostic factor for patients suffering from acute and chronic diseases, including cancer. In oncology patients, early diagnosis of cachexia and timely nutritional intervention have been demonstrated not only to prevent further deterioration of nutritional status, but also to increase quality of life and survival when integrated in a multiprofessional and multidisciplinary approach. However, nutritional therapy is associated to the possible development of complications, which may be fatal. Therefore, nutritional therapy in severely malnourished patients should be cautiously prescribed by experts in the field, who should develop a monitoring program to early detect complications and to maximise the clinical efficacy. Here we describe a cancer patient affected by refeeding syndrome, who was fortunately early diagnosed and properly treated.

INTRODUÇÃO: A síndrome de realimentação caracteriza-se por alterações neurológicas, sintomas respiratórios, arritmias e falência cardíacas, poucos dias após a realimentação. Ocorre em consequência do suporte nutricional (oral, enteral ou parenteral) em pacientes severamente desnutridos. OBJETIVO: Avaliar de suas causas e a aplicação das medidas dietéticas profiláticas apropriadas visando a prevenção e diminuição da morbimortalidade desta condição. MÉTODOS: Foi realizado levantamento bibliográfico na SciELO, LILACS, Medline/Pubmed, Biblioteca Cochrane e sites governamentais nos idiomas português, inglês e espanhol. Os levantamentos foram sobre os últimos 15 anos, selecionando os descritores: síndrome de realimentação, desnutrição, hipofosfatemia, hipocalemia, hipomagnesemia. CONCLUSÃO: O acompanhamento de parâmetros metabólicos e de níveis de eletrólitos antes do início do suporte nutricional e periodicamente durante a alimentação deve ser baseado em protocolos, no estado da doença subjacente e na duração da terapia. Equipe multidisciplinar de terapia nutricional pode orientar e educar outros profissionais de saúde na prevenção, diagnóstico e tratamento dessa síndrome.INTRODUCTION: Feedback syndrome is characterized clinically by neurological alterations, respiratory symptoms, arrhythmias and heart failure few days after refeeding. It happens due to severe electrolyte changes, such as hypophosphatemia, hypomagnesemia and hypokalemia associated with metabolic abnormalities that may occur as a result of nutritional support (oral, enteral or parenteral) in severely malnourished patients. OBJETIVE: To evaluate its causes and the preventive dietary measures aiming to reduce the morbimortality. METHODS: Was conducted literature review in SciELO, LILACS, Medline / Pubmed, Cochrane Library and government websites in Portuguese, English and Spanish. The survey was about the last 15 years, selecting the headings: refeeding syndrome, malnutrition, hypophosphatemia, hypokalemia, hypomagnesemia. CONCLUSION: The monitoring of metabolic parameters and electrolyte levels before starting nutritional support and periodically during feeding should be based on protocols and the duration of therapy. Patients at high risk and other metabolic complications should be followed closely, and depletion of minerals and electrolytes should be replaced before starting the diet. A multidisciplinary team of nutrition therapy can guide and educate other health professionals in prevention, diagnosis and treatment of the syndrome.

El Síndrome de Realimentación puede definirse como el conjunto de alteraciones metabólicas desencadenadas tras la rápida reintroducción del soporte nutricional (oral, enteral o parenteral) en pacientes con malnutrición calórico-proteica. Es un cuadro clínico normalmente infradiagnosticado en el entorno médico no especializado en nutrición, pero potencialmente grave. La principal herramienta para su prevención radica en la correcta identificación de los pacientes en riesgo de desarrollar SR, previa a la instauración del soporte nutricional. El presente caso describe las estrategias a seguir en la práctica clínica para la prevención del SR e instauración del soporte nutricional en un paciente en riesgo de desarrollar este síndrome.The refeeding syndrome can be defined as the metabolic alterations developed by the rapid nutrition repletion (oral, enteral as well as parenteral feeding) of severaly malnourished patients. Refeeding syndrome is a potentially fatal clinical condition and it is often underdiagnosed on non-specialized nutrition units. The most important key for its prevention is to identify patients at high risk for developing refeeding syndrome, before nutrition repletion. The present case describes the steps to prevent the refeeding syndrome as well as the clinical recommendations to restart nutrition support.

Hunger strike is a regularly reported problem in prison. Although clinical situations are rarely severe, hospitalisation is often considered. In consequence, it is not only physicians working in prisons, but also hospital medical teams who face challenges related to hunger strike, involving somatic, psychological, legal and human rights aspects. Furthermore, deontological rules must be strictly respected when delivering care, particularly in prison setting. Starvation involves metabolic changes and can cause severe, and sometimes even irreversible or fatal complications. Moreover, the phase of re-alimentation should not be trivialised, as re-feeding syndrome is a potentially fatal phenomenon. This article provides guidance for monitoring and management of patients on hunger strike.

Compared to enteral or hypocaloric oral nutrition, the use of PN (parenteral nutrition) is not associated with increased mortality, overall frequency of complications, or longer length of hospital stay (LOS). The risk of PN complications (e.g. refeeding-syndrome, hyperglycaemia, bone demineralisation, catheter infections) can be minimised by carefully monitoring patients and the use of nutrition support teams particularly during long-term PN. Occuring complications are e.g. the refeeding-syndrome in patients suffering from severe malnutrition with the initiation of refeeding or metabolic, hypertriglyceridemia, hyperglycaemia, osteomalacia and osteoporosis, and hepatic complications including fatty liver, non-alcoholic fatty liver disease, cholestasis, cholecystitis, and cholelithiasis. Efficient monitoring in all types of PN can result in reduced PN-associated complications and reduced costs. Water and electrolyte balance, blood sugar, and cardiovascular function should regularly be monitored during PN. Regular checks of serum electrolytes and triglycerides as well as additional monitoring measures are necessary in patients with altered renal function, electrolyte-free substrate intake, lipid infusions, and in intensive care patients. The metabolic monitoring of patients under long-term PN should be carried out according to standardised procedures. Monitoring metabolic determinants of bone metabolism is particularly important in patients receiving long-term PN. Markers of intermediary, electrolyte and trace element metabolism require regular checks.

Introduction: Celiac crisis is a life-threatening complication of celiac disease that is rarely described in adults. Case report: We report the case of a 31-year-old man with celiac crisis as a first manifestation of celiac disease. The patient presented with severe diarrhea, metabolic acidosis, and electrolyte disturbances accompanied by electrocardiographic alterations. A satisfactory clinical response was obtained after the correction of electrolyte abnormalities, hydration, and nutritional support with a gluten-free diet according to recommendations for patients at high risk of refeeding syndrome. Discussion: Celiac crisis generally occurs in patients with no previous diagnosis of celiac disease. The physician should therefore be aware of this diagnosis and consider celiac crisis in cases of unexplained intense secretory diarrhea, metabolic acidosis and severe electrolyte alterations in adults. The risk of refeeding syndrome should be assessed when a gluten-free diet is introduced and treatment of celiac crisis should include prevention and management of this possible complication.