Refeeding syndrome

Background

Mostly an issue with TPN, risk of death.

Pathophysiology

When a severely malnourished patient is given glucose, the following cascade of events takes place:

• Insulin is released
  • this stimulates drive to produce ATP
  • As ATP is produced, phosphorus is depleted
  • As ATP is produced, the cellular Na/K ATPase is activated, leading to transcellular movement of potassium and eventually other electrolytes, including magnesium, phosphorus and calcium into the cell.
  • this leads to hypokalemia, hypomagnesemia, and hypophosphatemia.
  • Metabolic acidosis also develops.
• Electrolyte abnormalities can cause prolonged QTc
• Rapid phosphorus depletion can lead to hemolysis, hypotension, altered mental status.

Clinical Features

• Fluid overload, CHF
• Altered mental status
• Seizure
• Rhabdomyolysis
• Hemolysis
• Symptomatic from hypophosphatemia, hypokalemia, hypomagnesemia

Differential Diagnosis

• Fluid overload
  • Insulin secretion
  • Loss of myocardium
  • Na absorption
• Mineral Depletion:
  • Phosphorus
  • K
  • Na
  • Mg
• Glucose Intolerance
• Cardiac arrhythmias
  • 1st wk
  • Long QT

Evaluation

Workup

• CBC
• Chemistry
• Magnesium
• Phosphorus
• ECG

Findings

• Hypokalemia, hypomagnesemia
• Metabolic acidosis
• ECG: May cause prolonged QTc
• Hypophosphatemia
  • Leading to hemolysis, hypotension, altered mental status

Management

ASPEN Consensus guidelines

See Also

• Nutrition (main)

References

1. Bhraonain, Sinead, et al. “Chronic malnutrition may in fact be an acute emergency.” The Journal of Emergency Medicine, 2013, Vol 44, issue 1, pages 72-74
2. Bjelakovic, Goran, et al. “Antioxidant Supplements for prevention of mortality in healthy participants and patients with various diseases.” Sao Paula Med J 2015; 133(2):164-165.