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Yang CJ, Chang CM, Chang GP, Tsai HT, Yu TY, Han YY. Unveiling the heightened susceptibility: Exploring early hypophosphatemia in critically ill trauma patients. J Formos Med Assoc 2024:S0929-6646(24)00286-9. [PMID: 38880709 DOI: 10.1016/j.jfma.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 05/31/2024] [Accepted: 06/12/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Phosphorus is a vital mineral crucial for various physiological functions. Critically ill trauma patients frequently experience hypophosphatemia during the immediate post-traumatic phase, potentially impacting outcomes. This study aims to investigate the incidence of early hypophosphatemia in critically major trauma patients. METHODS In this prospective observational study, trauma patients admitted to the intensive care unit (ICU) within one day were enrolled. These patients were categorized into Hypo-P groups and Non-hypo groups based on the development of new-onset hypophosphatemia within 72 h after feeding. The primary outcome assessed was the incidence of new-onset hypophosphatemia. The secondary outcomes included ICU and hospital stay, ventilation duration, and mortality. RESULTS 76.1% of patients developed a new onset of hypophosphatemia within 72 h after feeding. The Hypo-P group had significantly longer ICU stays (8.1 days ± 5.5 vs. 4.4 days ± 3.1; p = 0.0251) and trends towards extended hospital stay, ventilation duration, and higher mortality. Additionally, they demonstrated significantly higher urine fractional excretion of phosphate (FEPO4) on the first ICU day (29.2% ± 14.23 vs. 19.5% ± 8.39; p = 0.0242). CONCLUSION Critically ill trauma patients exhibited a significantly higher incidence of early hypophosphatemia than typical ICU rates, indicating their heightened vulnerability. The significantly high urine FEPO4 underscores the crucial role of renal loss in disrupting phosphate metabolism in this early acute phase after trauma. A significant correlation was observed between hypophosphatemia and longer ICU stays. Monitoring and managing phosphate levels may influence outcomes, warranting further investigation.
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Affiliation(s)
- Chi-Ju Yang
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Ming Chang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Environment and Occupational Health Sciences, National Taiwan University, Taipei, Taiwan
| | - Gyu-Ping Chang
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Huei-Ting Tsai
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ting-Yu Yu
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yin-Yi Han
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan; Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan.
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Chen S, Cai D, Lai Y, Zhang Y, He J, Zhou L, Sun H. Risk factors and outcomes for refeeding syndrome in acute ischaemic stroke patients. Nutr Diet 2024. [PMID: 38738826 DOI: 10.1111/1747-0080.12872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/24/2023] [Accepted: 03/04/2024] [Indexed: 05/14/2024]
Abstract
AIM Patients with acute ischaemic stroke are more likely to develop refeeding syndrome due to increased need for nutritional support when suffering alterations of consciousness and impairment of swallowing. This study aimed to evaluate the incidence, risk factors and outcomes of refeeding syndrome in stroke patients. METHODS This was a retrospective observational study, using the prospective stroke database from hospital, included all consecutive acute ischaemic stroke patients who received enteral nutrition for more than 72 h from 1 January 2020 and 31 December 2022. Refeeding syndrome was defined as occurrence of new-onset hypophosphataemia within 72 h after enteral feeding. Multiple logistic regression analysis was conducted to evaluate risk factors and relationships between refeeding syndrome and stroke outcomes. RESULTS 338 patients were included in the study. 50 patients (14.8%) developed refeeding syndrome. Higher scores on National Institutes of Health Stroke Scale and Nutritional Risk Screening 2002, albumin <30 g/L and BMI <18.5 kg/m2 were risk factors for refeeding syndrome. Moreover, refeeding syndrome was independently associated with a 3-month modified Rankin Scale score of >2 and 6-month mortality. CONCLUSIONS Refeeding syndrome was common in stroke patients and higher baseline National Institutes of Health Stroke Scale, higher Nutritional Risk Screening 2002, albumin <30 g/L and BMI <18.5 kg/m2 were independent risk factors of refeeding syndrome. Occurrence of refeeding syndrome was significantly associated with higher 3-month modified Rankin Scale and 6-month mortality.
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Affiliation(s)
- Shumin Chen
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Traditional Chinese University of Guangzhou, Foshan, China
| | - Dongchun Cai
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Traditional Chinese University of Guangzhou, Foshan, China
| | - Yuzheng Lai
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Traditional Chinese University of Guangzhou, Foshan, China
| | - Yongfang Zhang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianfeng He
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Traditional Chinese University of Guangzhou, Foshan, China
| | - Liang Zhou
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hao Sun
- Department of Neurology, Guangdong Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Affiliated Hospital of Traditional Chinese University of Guangzhou, Foshan, China
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Biolato M, Terranova R, Policola C, Pontecorvi A, Gasbarrini A, Grieco A. Starvation hepatitis and refeeding-induced hepatitis: mechanism, diagnosis, and treatment. Gastroenterol Rep (Oxf) 2024; 12:goae034. [PMID: 38708095 PMCID: PMC11069106 DOI: 10.1093/gastro/goae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 01/27/2024] [Accepted: 03/19/2024] [Indexed: 05/07/2024] Open
Abstract
Anorexia nervosa (AN) is one of the most common psychiatric disorders among young adults and is associated with a substantial risk of death from suicide and medical complications. Transaminase elevations are common in patients with AN at the time of hospital admission and have been associated with longer lengths of hospital stay. Multiple types of hepatitis may occur in these patients, including two types that occur only in patients with AN: starvation hepatitis and refeeding-induced hepatitis. Starvation hepatitis is characterized by severe transaminase elevation in patients in the advanced phase of protein-energy deprivation and is associated with complications of severe starvation, such as hypoglycaemia, hypothermia, and hypotension. Refeeding-induced hepatitis is characterized by a milder increase in transaminases that occurs in the early refeeding phase and is associated with hypophosphatemia, hypokalemia, and hypomagnesaemia. Among the most common forms of hepatitis, drug-induced liver injury is particularly relevant in this patient cohort, given the frequent use and abuse of methamphetamines, laxatives, antidepressants, and antipsychotics. In this review, we provided an overview of the different forms of anorexic-associated hepatitis, a diagnostic approach that can help the clinician to correctly frame the problem, and indications on their management and treatment.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Rosy Terranova
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Caterina Policola
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
- Unit of Endocrinology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alfredo Pontecorvi
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
- Unit of Endocrinology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome, Italy
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Matsunaga H, Riku K, Shimizu K, Fujimi S. Severe hypoglycemia with reduced liver volume as an indicator of end-stage malnutrition in patients with anorexia nervosa: a retrospective observational study. J Eat Disord 2024; 12:55. [PMID: 38702806 PMCID: PMC11069231 DOI: 10.1186/s40337-024-01011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/24/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Hypophosphatemia due to excessive carbohydrate administration is considered the primary pathogenesis of refeeding syndrome. However, its association with liver injury and hypoglycemia, often seen in severe malnutrition before re-nutrition, remains unclear. Autophagy reportedly occurs in the liver of patients with severe malnutrition. This study aimed to clarify the pathophysiology of liver injury and hypoglycemia by focusing on liver volume. METHODS Forty-eight patients with anorexia nervosa with a body mass index (BMI) of < 13 kg/m2 were included (median BMI: 10.51 kg/m2 on admission). Liver volume was measured in 36 patients who underwent abdominal computed tomography (CT), and the "estimated liver weight/ideal body weight" was used as the liver volume index. Seventeen blood test items were analyzed during the first 60 days. RESULTS Liver volume significantly decreased when abdominal CTs were conducted shortly before or after hypoglycemia compared to when the scans were performed during periods without hypoglycemia. Five patients with severe hypoglycemia on days 13-18 after admission had a very low nutritional intake; of them, four showed a marked decrease in liver volume. Severe hypoglycemia was accompanied by low serum triglycerides and liver dysfunction. Patients experiencing hypoglycemia of blood glucose levels < 55 mg/dL (< 3.05 mmol/L) (32 patients; median lowest BMI: 9.45 kg/m2) exhibited significantly poorer blood findings for most of the 17 items, except serum phosphorus and potassium, than did those not experiencing hypoglycemia (16 patients; median lowest BMI: 11.2 kg/m2). All patients with a poor prognosis belonged to the hypoglycemia group. Empirically, initiating re-nutrition at 500 kcal/day (20-25 kcal/kg/day), increasing to 700-800 kcal/day after a week, and then gradually escalating can reduce serious complications following severe hypoglycemia. CONCLUSIONS Liver volume reduction accompanied by hypoglycemia, low serum triglyceride levels, and liver dysfunction occurs when the body's stored energy sources are depleted and external nutritional intake is inadequate, suggesting that the liver was consumed as a last resort to obtain energy essential for daily survival. This pathophysiology, distinct from refeeding syndrome, indicates the terminal stage of malnutrition and is a risk factor for complications and poor prognosis. In treatment, extremely low nutrient levels should be avoided.
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Affiliation(s)
- Hidenori Matsunaga
- Department of Psychiatry, Osaka General Medical Center, Bandai-Higashi 3-1-56, Sumiyoshi-ku, Osaka, 558-8558, Japan.
- Department of Psychiatry, Osaka University Graduate School of Medicine, Yamada-Oka 2-2, Suita-City, Osaka, 565-0871, Japan.
- Department of Pharmacotherapeutics II, Faculty of Pharmacy, Osaka Medical and Pharmaceutical University, Nasahara 4-20-1, Takatsuki-City, Osaka, 569-1094, Japan.
| | - Keisen Riku
- Rikusato Kenko Clinic, Andoji-Machi, 2-6-3-102, Chuo-ku, Osaka, 542-0061, Japan
| | - Kentaro Shimizu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Yamada-Oka 2-2, Suita-City, Osaka, 565-0871, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Bandai-Higashi 3-1-56, Sumiyoshi-ku, Osaka, 558-8558, Japan
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Bolhuis I, Plötz FB, Bannink EMN, Hassing M, van Bellegem AC. Adherence to Dutch Guideline in Hospitalized Anorexia Nervosa Adolescents. Glob Pediatr Health 2024; 11:2333794X231221931. [PMID: 38188075 PMCID: PMC10768617 DOI: 10.1177/2333794x231221931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024] Open
Abstract
Background. The Dutch guideline Eating Disorders defines admission criteria for children with anorexia nervosa (AN) in need for medical stabilization and advices close monitoring to detect refeeding syndrome (RFS) in an early stage. Methods. Admission criteria, recommendations at admission, and during first week of hospitalization were evaluated in accordance to the guideline. RFS was defined as decreased electrolyte concentrations and/or clinical features. Results. 22 patients were included with a total of 50 admissions. We observed that 62% of the admitted patients met one of the admission criteria, 190/300 (63%) recommended admission examinations were performed. During admission adherence decreased, in particular daily weighing and physical examination (12% and 6%, respectively). The guideline was not fully followed in any of the patients. None of the hospitalized patients met the RFS criteria. Conclusion. Guideline adherence was moderate and can be improved by a few adaptations, which may limit unnecessary laboratory testing.
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Jaxa-Kwiatkowski A, Łysenko L, Gara-Rucińska M, Leszczyszyn A, Gerber H, Kubiak M. Potentially Lethal But Rarely Considered. Risk of Developing Refeeding Syndrome in Primary Oral Squamous Cell Carcinoma. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 125:101742. [PMID: 38141827 DOI: 10.1016/j.jormas.2023.101742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/14/2023] [Indexed: 12/25/2023]
Abstract
Presurgical preparation and postoperative care are cornerstones of all surgical procedures. Surgeons should be especially vigilant with malnourished cancer patients. Refeeding syn-drome (RFS) is a serious, potentially fatal complication of initiating appropriate nutrition in malnourished patients or after a period of starvation, although no standard precise definition has been proposed. The rarity of its une-quivocally life-threatening course means that its risk may be underestimated in clinical practice. The study's main goal was to assess the degree of malnutrition and the risk of RFS in the presurgical status of patients with oral cavity cancer and to identify risk factors for the occurrence of RFS. This single-center prospective observational study included patients diagnosed with oral squamous cell carcinoma. We investigated the relationship of RFS with age, BMI, features of the malignant tumor process selected internal medicine comorbidities, inflam-matory markers, renal and hepatic parameters, plasma levels of diverse electrolytes, and microelements were assessed. In the work, we utilized the National Institute for Health and Clinical Excellence (NICE) criteria. The study included 90 patients: 35 women and 55 men, aged 64.2±10.5. A robust statistical correlation at a significance level of p < 0.05 was demonstrated between advanced age, lower BMI, lymph node metastases, and a relatively low LDH as positive predictors of the onset of RFS and confirmed the high predictive value of the NRS-2002 scale. This paper seeks to call attention to RFS and identify critical issues that may be useful for its prevention.
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Affiliation(s)
| | - Lidia Łysenko
- Department of Anesthesiology and Intensive Therapy, Medical University Wroclaw, Poland
| | | | - Anna Leszczyszyn
- Oral Surgery outpatient Clinic, 4th Military Hospital,Weigla 5 Street Wroclaw
| | - Hanna Gerber
- Department of Maxillofacial Surgery, Medical University Wroclaw, Poland
| | - Marcin Kubiak
- Department of Maxillofacial Surgery, Medical University Wroclaw, Poland
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Crawford SG, Coker RH, O’Hara TM, Breed GA, Gelatt T, Fadely B, Burkanov V, Rivera PM, Rea LD. Fasting durations of Steller sea lion pups vary among subpopulations-evidence from two plasma metabolites. CONSERVATION PHYSIOLOGY 2023; 11:coad084. [PMID: 38026798 PMCID: PMC10673819 DOI: 10.1093/conphys/coad084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 08/28/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023]
Abstract
Geographic differences in population growth trends are well-documented in Steller sea lions (Eumetopias jubatus), a species of North Pacific pinniped listed under the U.S. Endangered Species Act in 1990 following a marked decline in population abundance that began during the 1970s. As population growth is intrinsically linked to pup production and survival, examining factors related to pup physiological condition provides useful information to management authorities regarding potential drivers of regional differences. During dam foraging trips, pups predictably transition among three fasting phases, distinguished by the changes in the predominant metabolic byproduct. We used standardized ranges of two plasma metabolites (blood urea nitrogen and β-hydroxybutyrate) to assign pups to fasting categories (n = 1528, 1990-2016, 12 subpopulations): Recently Fed-Phase I (digestion/assimilation-expected hepatic/muscle glycogen usage), Phase II (expected lipid utilization), transitioning between Phases II-III (expected lipid utilization with increased protein reliance), or Phase III (expected protein catabolism). As anticipated, the majority of pups were classified as Recently Fed-Phase I (overall mean proportion = 0.72) and few pups as Phase III (overall mean proportion = 0.04). By further comparing pups in Short (Recently Fed-Phase II) and Long (all other pups) duration fasts, we identified three subpopulations with significantly (P < 0.03) greater proportions of pups dependent upon endogenous sources of energy for extended periods, during a life stage of somatic growth and development: the 1) central (0.27 ± 0.09) and 2) western (0.36 ± 0.13) Aleutian Island (declining population trend) and 3) southern Southeast Alaska (0.32 ± 0.06; increasing population trend) subpopulations had greater Long fast proportions than the eastern Aleutian Islands (0.10 ± 0.05; stabilized population). Due to contrasting population growth trends among these highlighted subpopulations over the past 50+ years, both density-independent and density-dependent factors likely influence the dam foraging trip duration, contributing to longer fasting durations for pups at some rookeries.
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Affiliation(s)
- Stephanie G Crawford
- Department of Biology and Wildlife and Institute of Northern Engineering, University of Alaska Fairbanks, 1764 Tanana Loop, Fairbanks, Alaska 99775, USA
| | - Robert H Coker
- Montana Center for Work Physiology and Exercise Metabolism, University of Montana, 32 Campus Drive, Missoula, Montana 59812, USA
| | - Todd M O’Hara
- Veterinary Integrative Biosciences, School of Veterinary Medicine & Biomedical Sciences, Texas A&M University, 402 Raymond Stotzer Parkway, Bldg 2, College Station, Texas 77843, USA
| | - Greg A Breed
- Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, Alaska 99775, USA
| | - Tom Gelatt
- Marine Mammal Laboratory, Alaska Fisheries Science Center, National Marine Fisheries Service, National Oceanic and Atmospheric Administration, 7600 Sand Point Way N.E., Bldg. 4, Seattle, Washington 98115, USA
| | - Brian Fadely
- Marine Mammal Laboratory, Alaska Fisheries Science Center, National Marine Fisheries Service, National Oceanic and Atmospheric Administration, 7600 Sand Point Way N.E., Bldg. 4, Seattle, Washington 98115, USA
| | - Vladimir Burkanov
- Marine Mammal Laboratory, Alaska Fisheries Science Center, National Marine Fisheries Service, National Oceanic and Atmospheric Administration, 7600 Sand Point Way N.E., Bldg. 4, Seattle, Washington 98115, USA
| | - Patricia M Rivera
- Center for Alaska Native Health Research, Institute of Arctic Biology, University of Alaska Fairbanks, 2141 Koyukuk Drive, Fairbanks, Alaska 99775, USA
| | - Lorrie D Rea
- Institute of Northern Engineering, University of Alaska Fairbanks, 1764 Tanana Loop, Fairbanks, Alaska 99775, USA
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Crider A, Gillis C, Daniels L, Stern G. Association between dextrose-containing maintenance fluids and phosphorus supplementation during total parenteral nutrition initiation in adult patients who were hospitalized: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2023; 47:1021-1027. [PMID: 37732827 DOI: 10.1002/jpen.2562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 08/22/2023] [Accepted: 09/12/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Use of dextrose-containing maintenance fluids prior to parenteral nutrition (PN) initiation is speculated to reduce the risk for refeeding syndrome. We aimed to assess if the use of dextrose vs nondextrose maintenance fluids before PN initiation changes electrolyte supplementation requirements and shifts during initiation. METHODS This retrospective cohort study included patients who received nothing by mouth but received maintenance fluids ≥72 h before PN. The major end point was phosphorus supplementation over 48 h following nutrition initiation. Minor end point included other electrolyte supplementation, changes in electrolyte levels, time to discharge, and goal kilocalories per day. RESULTS Fifty-three patients between August 1, 2019, and August 26, 2020, met criteria for analysis; 60% (n = 32) used a dextrose and 40% (n = 21) used a nondextrose maintenance fluid. Baseline characteristics were similar between fluid groups except for body mass index (25.1 dextrose vs 27.5 kg/m2 nondextrose), sex (43.8% female vs 52.4% male), and severe malnutrition (46.9% vs 28.6%), respectively. Phosphorus (52.5 vs 50 mmol; P = 0.33) and magnesium (24 vs 22 g; P = 0.63) supplementation 48 h following nutrition initiation were similar between groups; however, potassium supplementation was lower in the dextrose group (165.0 vs 208.7 mEq; P = 0.01). No difference was observed between groups for time to discharge following nutrition initiation or time to goal kilocalories per day. After controlling for patients who were malnourished between fluid groups using linear regression, phosphorus repletion differences remained nonsignificant. CONCLUSION This study did not detect a difference in phosphorus supplementation between groups, even after controlling for patients who were malnourished.
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Affiliation(s)
- Anna Crider
- Department of Pharmacy, Emory University Hospital, Atlanta, Georgia, USA
| | - Christine Gillis
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lauren Daniels
- Nutrition Support Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gretchen Stern
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Little BS, Pinto SR, Buckley D, Han DY, Cormack BE. Hypophosphataemia definitions, incidence and associated outcomes in paediatric intensive care: A retrospective cohort study in post-cardiac surgical patients <2 years of age. J Paediatr Child Health 2023; 59:1075-1081. [PMID: 37335265 DOI: 10.1111/jpc.16457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 05/08/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023]
Abstract
AIM Hypophosphataemia has been linked to higher morbidity and mortality in intensive care but there is inconsistency in the definition of hypophosphataemia for infants and children. We aimed to determine the incidence of hypophosphataemia in a group of at-risk children in paediatric intensive care unit (PICU) and associations with patient characteristics and clinical outcomes using three different hypophosphataemia thresholds. METHODS Retrospective cohort study of 205 post-cardiac surgical patients <2 years of age admitted to Starship Child Health PICU, Auckland, New Zealand. Patient demographics and routine daily biochemistry for 14 days after PICU admission were collected. Rates of sepsis, mortality and length of mechanical ventilation were compared between groups with different serum phosphate concentrations. RESULTS Out of 205 children, 6 (3%), 50 (24%) and 159 (78%) had hypophosphataemia at thresholds of <0.7, <1.0 and <1.4 mmol/L, respectively. There were no differences in gestational age at birth, sex, ethnicity or mortality in those with and without hypophosphataemia at any threshold. Children with a serum phosphate <1.4 mmol/L had more mean (SD) total hours of mechanical ventilation (85.2 (79.6) vs. 54.9 (36.2) h, P = 0.02) and those with mean serum phosphate <1.0 mmol/L had more mean hours of mechanical ventilation (119.4 (102.8) vs. 65.2 (54.8) h, P < 0.0001), episodes of sepsis (14% vs. 5%, P = 0.03) and longer length of stay (6.4 (4.8-20.7) vs. 4.9 (3.9-6.8) days, P = 0.02). CONCLUSIONS Hypophosphataemia is common in this PICU cohort and serum phosphate <1.0 mmol/L is associated with increased morbidity and length of stay.
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Affiliation(s)
- Bridget S Little
- Starship Child Health, Auckland City Hospital, Auckland, New Zealand
| | - Shalom R Pinto
- Starship Child Health, Auckland City Hospital, Auckland, New Zealand
- Department of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - David Buckley
- Starship Child Health, Auckland City Hospital, Auckland, New Zealand
| | - Dug Y Han
- Starship Child Health, Auckland City Hospital, Auckland, New Zealand
| | - Barbara E Cormack
- Starship Child Health, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, University of Auckland, Auckland, New Zealand
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Heuft L, Voigt J, Selig L, Schmidt M, Eckelt F, Steinbach D, Federbusch M, Stumvoll M, Schlögl H, Isermann B, Kaiser T. Development, Design and Utilization of a CDSS for Refeeding Syndrome in Real Life Inpatient Care-A Feasibility Study. Nutrients 2023; 15:3712. [PMID: 37686744 PMCID: PMC10490138 DOI: 10.3390/nu15173712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND The refeeding syndrome (RFS) is an oftentimes-unrecognized complication of reintroducing nutrition in malnourished patients that can lead to fatal cardiovascular failure. We hypothesized that a clinical decision support system (CDSS) can improve RFS recognition and management. METHODS We developed an algorithm from current diagnostic criteria for RFS detection, tested the algorithm on a retrospective dataset and combined the final algorithm with therapy and referral recommendations in a knowledge-based CDSS. The CDSS integration into clinical practice was prospectively investigated for six months. RESULTS The utilization of the RFS-CDSS lead to RFS diagnosis in 13 out of 21 detected cases (62%). It improved patient-related care and documentation, e.g., RFS-specific coding (E87.7), increased from once coded in 30 month in the retrospective cohort to four times in six months in the prospective cohort and doubled the rate of nutrition referrals in true positive patients (retrospective referrals in true positive patients 33% vs. prospective referrals in true positive patients 71%). CONCLUSION CDSS-facilitated RFS diagnosis is possible and improves RFS recognition. This effect and its impact on patient-related outcomes needs to be further investigated in a large randomized-controlled trial.
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Affiliation(s)
- Lara Heuft
- Institute of Human Genetics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Jenny Voigt
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Lars Selig
- Department of Endocrinology, Nephrology and Rheumatology, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Maria Schmidt
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Felix Eckelt
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Daniel Steinbach
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Martin Federbusch
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Michael Stumvoll
- Department of Endocrinology, Nephrology and Rheumatology, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Haiko Schlögl
- Department of Endocrinology, Nephrology and Rheumatology, University Medical Center Leipzig, 04103 Leipzig, Germany
- Helmholtz Institute for Metabolic, Obesity and Vascular Research (HI-MAG) of the Helmholtz Zentrum München at University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Berend Isermann
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
| | - Thorsten Kaiser
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Medical Center Leipzig, 04103 Leipzig, Germany
- Institute for Laboratory Medicine, Microbiology and Pathobiochemistry, Medical School and University Medical Center OWL, Hospital Lippe, Bielefeld University, 32756 Bielefeld, Germany
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Collie JTB, Jiang A, Abdelhamid YA, Ankravs M, Bellomo R, Byrne KM, Clancy A, Finnis ME, Greaves R, Tascone B, Deane AM. Relationship of blood thiamine pyrophosphate to plasma phosphate and the response to enteral nutrition plus co-administration of intravenous thiamine during critical illness. J Hum Nutr Diet 2023; 36:1214-1224. [PMID: 36919646 DOI: 10.1111/jhn.13162] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/06/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Hypovitamin B1 occurs frequently during critical illness but is challenging to predict or rapidly diagnose. The aim of this study was to evaluate whether plasma phosphate concentrations predict hypovitamin B1, enteral nutrition prevents hypovitamin B1 and intravenous thiamine supplementation achieves supraphysiological concentrations in critically ill patients. METHODS Thirty-two enterally fed critically ill patients, with a plasma phosphate concentration ≤0.65 mmol/L, formed a nested cohort within a larger randomised clinical trial. Patients were assigned to receive intravenous thiamine (200 mg) twice daily, and controls were not administered intravenous thiamine. Thiamine pyrophosphate concentrations were measured at four time points (pre- and post-infusion and 4- and 6-h post-infusion) on days 1 and 3 in those allocated to thiamine and once in the control group. RESULTS Baseline thiamine pyrophosphate concentrations were similar (intervention 88 [67, 93] vs. control 89 [62, 110] nmol/L, p = 0.49). Eight (25%) patients had hypovitamin B1 (intervention 3 vs. control 5), with two patients in the control group remaining insufficient at day 3. There was no association between baseline phosphate and thiamine pyrophosphate concentrations. Intravenous thiamine achieved supraphysiological concentrations 6 h post first infusion, with concentrations increasing to day 3. In the control group, thiamine pyrophosphate concentrations were not statistically different between baseline and day 3 (mean change: 8.6 [-6.0, 23.1] nmol/L, p = 0.25). CONCLUSIONS Phosphate concentrations did not predict hypovitamin B1, which was observed in 25% of the participants. Enteral nutrition alone prevented the development of new hypovitamin B1. Administration of a single 200-mg dose of intravenous thiamine achieved supraphysiological concentrations of thiamine pyrophosphate, with repeated dosing sustaining this effect.
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Affiliation(s)
- Jake T B Collie
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- Agilent Technologies, Melbourne, Victoria, Australia
| | - Alice Jiang
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melissa Ankravs
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Kathleen M Byrne
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Annabelle Clancy
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Mark E Finnis
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ronda Greaves
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- Department of Biochemical Genetics, Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Brianna Tascone
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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12
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Mosuka EM, Murugan A, Thakral A, Ngomo MC, Budhiraja S, St Victor R. Clinical Outcomes of Refeeding Syndrome: A Systematic Review of High vs. Low-Calorie Diets for the Treatment of Anorexia Nervosa and Related Eating Disorders in Children and Adolescents. Cureus 2023; 15:e39313. [PMID: 37351245 PMCID: PMC10281854 DOI: 10.7759/cureus.39313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 06/24/2023] Open
Abstract
Over the years, the standard of care for re-alimentation of patients admitted for the treatment of anorexia nervosa (AN) has been a conservative or cautious approach described as "start low and go slow." These traditional refeeding protocols advocate for a low-calorie diet that restricts carbohydrates, with the primary goal of hypothetically lowering the risk of refeeding syndrome (RFS) and its complication. However, no consensus exists for the optimal inpatient approach to refeeding children and adolescents with AN. There is still some disagreement about what constitutes an ideal pace for nutritional rehabilitation. Varying treatment protocols have emerged across the globe, often reflecting the preferences and biases of individual practitioners and contributing to the lack of a universally accepted protocol for refeeding in AN. Although it is widely accepted that low-caloric refeeding (LCR) is safe for inpatient treatment of AN, this strategy has been shown to have several significant drawbacks, leading to increased criticism of the LCR method. Research from the last decade has led to calls for a more aggressive refeeding protocol, one that suggests a higher caloric intake from the offset. As a result, this research aimed to conduct a systematic review of the existing literature on strategies for refeeding hospitalized pediatric/adolescent patients with AN and related eating disorders. We aimed to compare high-caloric refeeding (HCR) and LCR in terms of weight gain, length of stay, and risk of RFS. We conducted a thorough search of medical databases for abstracts published in English, including Google Scholar, PubMed, and MEDLINE, to find relevant studies published between 2010 and February 2023. Our focus was on articles that evaluated high versus low refeeding protocols in children and adolescents hospitalized for treating AN and related eating disorders. Only articles that reported on at least one of the outcome variables of interest, such as hypophosphatemia, weight gain, RFS, or length of hospital stay, were considered. This review included 20 full-text articles published in the last decade on the HCR protocol in children and adolescents, with a total sample size of 2191 participants. In only one of the 20 studies did researchers find evidence of a true clinical case of RFS. We, therefore, found no evidence that HCR increased the risk of RFS in adolescents, even in those with a very low body mass index (BMI). However, evidence suggests a lower BMI at the time of hospital admission is a better predictor of hypophosphatemia than total caloric intake. In conclusion, based on the evidence from this review, a high-caloric diet or rapid refeeding in children/adolescents suffering from AN may be both safe and effective, with serial laboratory investigations and phosphate supplementation as needed. Hence, more research, particularly, randomized controlled trials, is required to help shape an evidence-based refeeding guideline outlining target calorie intakes and rates of advancement to assist clinicians in the treatment of adolescents with AN and related eating disorders.
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Affiliation(s)
- Emmanuel M Mosuka
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
| | - Anushree Murugan
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
| | - Abhinav Thakral
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
| | - Mbelle C Ngomo
- Medicine, Université de Yaoundé, Faculté de Médecine et des Sciences Biomédicales, Yaoundé, CMR
| | - Sushil Budhiraja
- Pediatrics, Brookdale University Hospital Medical Center, New York, USA
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13
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Robinson DT, Taylor SN, Moya F. Preterm infant nutrition: considerations for infants at risk of refeeding syndrome. J Perinatol 2023; 43:120-123. [PMID: 36414735 DOI: 10.1038/s41372-022-01531-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022]
Abstract
Refeeding syndrome (RS) in preterm infants is a scenario of fetal malnutrition, primarily resulting from placental insufficiency, followed by a postnatal physiologic adaptation and response to an imbalance of nutrients provided parenterally. Growth restriction and small gestational age status are common findings in infants at risk of developing RS. Adverse clinical outcomes associated with RS may be severe and life-threatening. The biochemical abnormalities that occur in RS may be mitigated through careful monitoring and adaptation of the clinical management of parenteral and enteral nutrition. This perspective reviews the physiology and metabolism in infants with RS and provides suggested approaches to their clinical monitoring and nutritional management.
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Affiliation(s)
- Daniel T Robinson
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Sarah N Taylor
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Fernando Moya
- Department of Pediatrics, University of North Carolina School of Medicine, Wilmington, NC, USA
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14
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Refeeding Syndrome: A Critical Reality in Patients with Chronic Disease. Nutrients 2022; 14:nu14142859. [PMID: 35889815 PMCID: PMC9324596 DOI: 10.3390/nu14142859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 06/30/2022] [Accepted: 07/06/2022] [Indexed: 02/04/2023] Open
Abstract
Malnutrition is one of the most frequent metabolic challenges in the population of chronically ill patients. This results in increased administration of nutritional therapy in inpatient settings, which poses the risk of side effects, in particular, the development of refeeding syndrome. If not managed accordingly, it leads to a significant rise in morbidity and mortality. However, despite its importance, evidence-based recommendations on the management of refeeding syndrome are largely lacking, and only a few randomized controlled trials have been conducted. In light of this, the aim of this review is to raise awareness of refeeding syndrome in chronically ill patients by critically reviewing recent literature and providing a short overview as well as diagnosis and treatment algorithms of this underreported metabolic condition. In summary, recent findings suggest undergoing risk assessment and stratification for every patient receiving nutritional therapy. According to this, adaptation of energy and fluid support during the replenishment phase should be implemented in the nutritional therapy for patients at high risk. Additionally, continuous monitoring should take place, and appropriate actions should be initiated when necessary.
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15
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Draffin K, Hamilton J, Godsil S, Rudolph S, Crowe T, Newton R. Comparison of a low carbohydrate intake and standard carbohydrate intake on refeeding hypophosphatemia in children and adolescents with anorexia nervosa: a pilot randomised controlled trial. J Eat Disord 2022; 10:50. [PMID: 35413883 PMCID: PMC9006566 DOI: 10.1186/s40337-021-00519-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
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 (< 40% total energy from carbohydrate) or standard carbohydrate (50-60% total energy from carbohydrate). Serum phosphate levels were monitored daily across the first week and twice weekly thereafter. Clinical status, including weight gain, was monitored throughout admission. RESULTS 52% (n = 12) of participants were allocated to the low carbohydrate group and 48% (n = 11) were allocated to the standard carbohydrate group. No patients in either of the diet groups developed refeeding hypophosphatemia in the first seven days of admission. Weight gain during the first week was significantly higher in the standard carbohydrate diet (1.4 kg/wk ± 0.5) compared to the low carbohydrate diet (0.6 kg/wk ± 0.9), p value 0.03. Participants from both diet groups were largely orally fed with less than 10% of the total number of meals and/or snacks across both groups provided as nutrition supplement drinks, either orally or enterally. CONCLUSION This pilot study supports that a standard carbohydrate intake (providing 50-60% of total energy from carbohydrate) optimises nutritional rehabilitation without increasing the risk of refeeding hypophosphatemia in adolescent inpatients with anorexia nervosa. CTN: ACTRN12621000300875. Plain English Summary: People with eating disorders who are underweight or malnourished, such as patients with anorexia nervosa, are at risk of refeeding syndrome when they receive treatment and return to regular eating. Refeeding syndrome may cause fluid and electrolyte shifts. This can occur as a result of the reintroduction of carbohydrates, and can have potentially life-threatening consequences if not managed appropriately. Refeeding hypophosphatemia is one of the early markers of refeeding syndrome. This study compared patients who were provided a low carbohydrate diet (40% total energy from carbohydrate) to those who were provided a standard carbohydrate diet (50-60% total energy from carbohydrate) to see if patients from either group were more at risk of developing refeeding syndrome. No patients in either of the diet groups developed refeeding hypophosphatemia. This pilot study may help to ensure that when patients get treated for their eating disorder in hospital, they can return to a normal diet as soon as possible with close medical monitoring.
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16
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The epidemiology, impact, and diagnosis of micronutrient nutritional dermatoses. Part 2: B-complex vitamins. J Am Acad Dermatol 2022; 86:281-292. [DOI: 10.1016/j.jaad.2021.06.900] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/20/2021] [Accepted: 06/08/2021] [Indexed: 12/15/2022]
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Li J, Lu K, Zhang X, Wang T, Li Q, Yu X, Han W, Sun L. SIRT3-mediated mitochondrial autophagy in refeeding syndrome-related myocardial injury in sepsis rats. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:211. [PMID: 35280405 PMCID: PMC8908121 DOI: 10.21037/atm-22-222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/18/2022] [Indexed: 12/02/2022]
Abstract
Background Myocardial injury induced by refeeding syndrome (RFS) is one of the important causes of deterioration in critically ill patients. Sirtuin-3 (SIRT3) has been shown to regulate mitochondrial autophagy in myocardial ischemia/reperfusion injury; however, the role of mitochondrial autophagy on RFS-related myocardial injury in patients in critical condition has not been reported on. Methods Thirty Sprague-Dawley (SD) rats were divided into 3 groups (n=10 each group): the control group; the standard calorie refeeding (SCR) group; and the low calorie refeeding (LCR) group. The rats were weighed every third or four days from day 1 to day 14. On day 14, all rats were anesthetized and received an echocardiography test. Blood and bronchoalveolar lavage fluid (BALF) were collected and tested for arterial oxygen pressure (PaO2), phosphorus (P), and calcium (Ca), creatine kinase-MB (CK-MB), lactate dehydrogenase (LDH), and cardiac troponin 1 (cTnI), myeloperoxidase (MPO), tumor necrosis factor α (TNF-α), interleukin-1β (IL-1β), and IL-6. The histopathological change of hearts and lungs were evaluated, and lung injury score was calculated. Mitochondrial autophagy related proteins (including Beclin1, LC3, mitofusin-2, Mfn2, PINK1, Parkin, and SIRT3) were analyzed using a Western blot. To evaluate the effect of SIRT3, 20 rats were divided into 2 groups (n=10 each group): The adeno-associated virus 9 (AAV9-Nc) group; and the AAV9-SIRT3 overexpression (AAV9-SIRT3) group. The protocols for rats were the same as the SCR group since day 22 after injection of AAV9. The protein expressions of PINK1, Parkin, and SIRT3 were compared between the AAV9-Nc group and AAV9-SIRT3 group. Results SCR caused significant decline in cardiac contractility and increased inflammatory cell infiltration in myocardial tissue. Meanwhile, Beclin1, LC3, PINK1, Parkin, and SIRT3 levels decreased, while Mfn2 showed no significant change. Furthermore, significant positive correlations were also found between SIRT3 and P, PINK1, and Parkin, and significant negative correlations were found between SIRT3 and CK-MB, LDH, and cTnI. Overexpression of SIRT3 activated the PINK1/Parkin mediated mitochondrial autophagy. Conclusions SIRT3 has an essential role in RFS-related myocardial injury during LPS induced chronic sepsis in rats, probably via regulating mitochondrial autophagy.
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Affiliation(s)
- Jiucui Li
- Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Kongmiao Lu
- Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Xiao Zhang
- Department of Anesthesiology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Tianying Wang
- Clinical Research Center, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Qinghai Li
- Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Xinjuan Yu
- Clinical Research Center, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Wei Han
- Department of Pulmonary and Critical Care Medicine, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
| | - Lixin Sun
- Department of Anesthesiology, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao, China
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18
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Schunemann MJ, Bertschinger M, Trachsel C, Bachli E. Severe refeeding syndrome after human chorionic gonadotropin diet: a potentially lethal complication. BMJ Case Rep 2021; 14:e244011. [PMID: 34789523 PMCID: PMC8601063 DOI: 10.1136/bcr-2021-244011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 11/04/2022] Open
Abstract
We present the case of a young male patient who presented with paralysing muscle weakness due to severe hypokalaemia and hypophosphataemia. The initial patient history evaluations could not establish the aetiology. Only after we reviewed the patient's history did he reveal that he had been following a severe calorie-restricted regime, the human chorionic gonadotropin diet, which had ended 2 days prior to developing symptoms. This information then allowed us to diagnose severe refeeding syndrome. As a further complication, the patient developed rhabdomyolysis. After correction of serum electrolytes, symptoms resolved completely. This case emphasises the potential harm of severely calorie-restricted diets, often recommended by online 'experts'. Furthermore, we underline the importance of thorough history taking.
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Affiliation(s)
- Max J Schunemann
- Department of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Martina Bertschinger
- Department of Oncology and Haematology, Kantonsspital Winterthur, Winterthur, Switzerland
| | | | - Esther Bachli
- Inflammation Research Unit, Department for Internal Medicine, University Hospital Zurich, Schlieren, Switzerland
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19
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Bioletto F, Pellegrini M, Ponzo V, Cioffi I, De Francesco A, Ghigo E, Bo S. Impact of Refeeding Syndrome on Short- and Medium-Term All-Cause Mortality: A Systematic Review and Meta-Analysis. Am J Med 2021; 134:1009-1018.e1. [PMID: 33864767 DOI: 10.1016/j.amjmed.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND The refeeding syndrome has been described as a potentially life-threatening complication of renutrition. However, moving from single reports to larger population studies, the real impact of refeeding syndrome on all-cause mortality is still unknown. METHODS PubMed/Medline, EMBASE, Cochrane library, and CINAHL databases were systematically searched until September 2020 for studies reporting mortality rates in patients who developed the syndrome at renutrition compared with those who did not develop it. Effect sizes were pooled through a random-effect model. RESULTS Thirteen studies were finally considered in the meta-analysis, for a total of 3846 patients (mean age 64.5 years; 58% males). Pooled data showed a nonsignificant trend toward an increased short-term (≤1 month) mortality in patients developing the refeeding syndrome (odds ratio = 1.27, 95% confidence interval 0.93-1.72), mostly driven by studies in which renutrition was not prescribed and supervised by a nutritional support team (P = .01 at subgroup analysis) and by studies published in previous years (P = .04 at meta-regression). When examining medium-term (≤6 month) mortality, an overall statistical significance toward higher risk was observed (odds ratio = 1.54, 95% confidence interval 1.04-2.28). CONCLUSION This was the first meta-analysis that specifically assessed the impact of refeeding syndrome on mortality. Our results suggested a nonsignificant trend toward increased mortality in the short term but a significantly increased mortality in the medium term. The supervision/management of the refeeding process by a nutrition specialist might be a key factor for the limitation of this mortality excess.
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Affiliation(s)
- Fabio Bioletto
- Department of Medical Sciences, University of Turin, Turin, Italy.
| | | | - Valentina Ponzo
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Iolanda Cioffi
- Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Antonella De Francesco
- Dietetic and Clinical Nutrition, "Città della Salute e della Scienza" Hospital, Turin, Italy
| | - Ezio Ghigo
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Simona Bo
- Department of Medical Sciences, University of Turin, Turin, Italy
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Pan X, Chu R, Meng J, Wang Q, Zhang Y, Song K, Yang X, Kong B. Hyperemesis gravidarum induced refeeding syndrome causes blood cell destruction: a case report and literature review. BMC Pregnancy Childbirth 2021; 21:366. [PMID: 33966630 PMCID: PMC8108454 DOI: 10.1186/s12884-021-03821-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 04/21/2021] [Indexed: 11/24/2022] Open
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.
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Affiliation(s)
- Xiyu Pan
- Department of Obstetrics Gynecology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Shandong, 250012, Jinan, China
| | - Ran Chu
- Department of Obstetrics Gynecology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Shandong, 250012, Jinan, China
| | - Jinyu Meng
- Department of Obstetrics Gynecology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Shandong, 250012, Jinan, China
| | - Qiannan Wang
- Department of Obstetrics Gynecology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Shandong, 250012, Jinan, China
| | - Yue Zhang
- Department of Obstetrics Gynecology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Shandong, 250012, Jinan, China
| | - Kun Song
- Department of Obstetrics Gynecology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Shandong, 250012, Jinan, China.
| | - Xingsheng Yang
- Department of Obstetrics Gynecology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Shandong, 250012, Jinan, China
| | - Beihua Kong
- Department of Obstetrics Gynecology, Cheeloo College of Medicine, Qilu Hospital, Shandong University, Shandong, 250012, Jinan, China
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Abstract
Beriberi is a nutritional complication of gastric surgery, caused by deficiency of vitamin B1, or thiamine. Thiamine deficiency leads to impaired glucose metabolism, decreased delivery of oxygen by red blood cells, cardiac dysfunction, failure of neurotransmission, and neuronal death. This review describes the history and pathophysiology of beriberi as well as the relationship between beriberi and nutritional deficiencies after gastric surgery. A literature review of the history and pathophysiology of beriberi and the risk factors for thiamine deficiency, particularly after gastric resection or bariatric surgery, was performed. Recommendations for nutritional follow-up post gastric surgery are based on current national guidelines. Patients may have subclinical thiamine deficiency after upper gastrointestinal surgery, and thus beriberi may be precipitated by acute illness such as sepsis or poor dietary intake. This may occur very soon or many years after gastrectomy or bariatric surgery, even in apparently well-nourished patients. Prompt recognition and administration of supplemental thiamine can decrease morbidity and mortality in patients with beriberi. Dietary education post surgery and long-term follow-up to determine nutritional status, including vitamin and mineral assessment, is recommended for patients who undergo gastric surgery.
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Affiliation(s)
- Robert Beaumont Wilson
- Upper Gastrointestinal Surgery Department, University of New South Wales, Liverpool Public Hospital, Liverpool, Sydney, New South Wales, Australia, and the Sydney Institute for Obesity Surgery, Ashfield, Sydney, New South Wales, Australia
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Hardy G, Wong T, Morrissey H, Anderson C, Moltu SJ, Poindexter B, Lapillonne A, Ball PA. Parenteral Provision of Micronutrients to Pediatric Patients: An International Expert Consensus Paper. JPEN J Parenter Enteral Nutr 2021; 44 Suppl 2:S5-S23. [PMID: 32767589 DOI: 10.1002/jpen.1990] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 08/04/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Micronutrients (vitamins and trace elements) are essential to all nutrition. For children and neonates who are dependent upon nutrition support therapies for growth and development, the prescribed regimen must supply all essential components. This paper aims to facilitate interpretation of existing clinical guidelines into practical approaches for the provision of micronutrients in pediatric parenteral nutrition. METHODS An international, interdisciplinary expert panel was convened to review recent evidence-based guidelines and published literature to develop consensus-based recommendations on practical micronutrient provision in pediatric parenteral nutrition. RESULTS The guidelines and evidence have been interpreted as answers to 10 commonly asked questions around the practical principles for provision and monitoring of micronutrients in pediatric patients. CONCLUSION Micronutrients are an essential part of all parenteral nutrition and should be included in the pediatric nutrition therapy care plan.
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Affiliation(s)
- Gil Hardy
- Ipanema Research Trust, Auckland, New Zealand
| | - Theodoric Wong
- Consultant Pediatric Gastroenterologist, Women's and Children's Hospital, Birmingham, UK
| | - Hana Morrissey
- School of Pharmacy and Pharmaceutical Science, Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
| | - Collin Anderson
- Pharmacy, Intermountain Healthcare Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Sissel J Moltu
- Department of Neonatology, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Brenda Poindexter
- Department of Pediatrics, Cincinnati Children's Hospital and Medical Centre, Cincinnati, Ohio, USA
| | | | - Patrick A Ball
- School of Pharmacy and Pharmaceutical Science, Faculty of Science and Engineering, University of Wolverhampton, Wolverhampton, UK
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Abstract
Malnutrition and issues of nutrition are common in hospitalized patients. Identifying patients at nutritional risk can help to improve hospital-related outcomes. Specialized nutritional support in the form of oral nutritional supplementation, enteral nutrition, and parenteral nutrition is essential to meeting the nutritional needs of many patients. Disease-specific nutritional considerations are fundamental to the quality care of hospitalized patients. Many vitamin, macronutrient, and micronutrient deficiencies are relevant in hospital setting.
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Abstract
Hyperemesis gravidarum (HG) is a debilitating and potentially life-threatening pregnancy disease marked by weight loss, malnutrition, and dehydration attributed to unrelenting nausea and/or vomiting; HG increases the risk of adverse outcomes for the mother and child(ren). The complexity of HG affects every aspect of a woman's life during and after pregnancy. Without methodical intervention by knowledgeable and proactive clinicians, life-threatening complications may develop. Effectively managing HG requires an understanding of both physical and psychosocial stressors, recognition of potential risks and complications, and proactive assessment and treatment strategies using innovative clinical tools.
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Mouillot T, Brindisi MC, Chambrier C, Audia S, Brondel L. [Refeeding syndrome]. Rev Med Interne 2021; 42:346-354. [PMID: 33549330 DOI: 10.1016/j.revmed.2020.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 11/22/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- T Mouillot
- Service d'hépato-gastro-entérologie, CHU F.-Mitterrand, 21000 Dijon, France; AgroSup Dijon, CNRS, Inrae, centre des sciences du goût et de l'alimentation, université Bourgogne Franche-Comté, 21000 Dijon, France.
| | - M-C Brindisi
- AgroSup Dijon, CNRS, Inrae, centre des sciences du goût et de l'alimentation, université Bourgogne Franche-Comté, 21000 Dijon, France; Service d'endocrinologie et diabétologie, CHU F.-Mitterrand, 21000 Dijon, France
| | - C Chambrier
- Service de nutrition clinique intensive, hospices civils de Lyon, hôpital Lyon sud, 69495 Pierre-Bénite, France
| | - S Audia
- Service de médecine interne 1, CHU F.-Mitterrand, 21000 Dijon, France
| | - L Brondel
- Service d'hépato-gastro-entérologie, CHU F.-Mitterrand, 21000 Dijon, France; AgroSup Dijon, CNRS, Inrae, centre des sciences du goût et de l'alimentation, université Bourgogne Franche-Comté, 21000 Dijon, France
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Lo Gullo A, Rifici C, Caliri S, Donato A, De Cola MC, Di Cara M, Corallo F, Bramanti P, Giuffrida C. Refeeding syndrome in a woman with pancreatitis: a case report. J Int Med Res 2021; 49:300060520986675. [PMID: 33535848 PMCID: PMC7871053 DOI: 10.1177/0300060520986675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Refeeding syndrome can occur in malnourished patients with acute pancreatitis who have electrolyte imbalances. Refeeding syndrome is characterized by severe electrolyte imbalances (mainly hypophosphatemia, hypomagnesemia, and hypokalemia), vitamin deficiency (mainly thiamine deficiency), fluid overload, and salt retention resulting in organ dysfunction and cardiac arrhythmias. We herein report a case involving a patient with severe pancreatitis and gallbladder stones who developed refeeding syndrome with shock and loss of consciousness. The patient was treated by opportune vitamin and electrolyte supplementation therapy and showed substantial improvement after 2 weeks of hospitalization, gaining the ability to eat small bites of solid food orally. Early diagnosis and treatment of refeeding syndrome may reduce morbidity and mortality in patients with acute pancreatitis. Patients should be fasted only if alimentation is contraindicated, and electrolyte values must be closely monitored.
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Cook S, Whitby E, Elias N, Hall G, Chan DL. Retrospective evaluation of refeeding syndrome in cats: 11 cases (2013-2019). J Feline Med Surg 2021; 23:883-891. [PMID: 33404281 DOI: 10.1177/1098612x20979706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The aim of this study was to describe the clinicopathological findings, management and outcome of cats with refeeding syndrome (RS) following prolonged starvation. METHODS Records from four referral hospitals were searched between May 2013 and November 2019 and retrospectively evaluated. Inclusion criteria were the presence of a risk factor for RS, such as severe weight loss or emaciation following a period of presumed starvation, hypophosphataemia or a delta phosphorous exceeding 30% reduction following refeeding, being treated on the basis of a clinical diagnosis of RS and one or more derangement of hypokalaemia, hypoglycaemia or hyperglycaemia. RESULTS Eleven cats were identified, which had been missing for a median of 6 weeks (range 3-104 weeks). Mean ± SD percentage weight loss was 46% ± 7% (n = 8). Eight of 11 cats developed hypophosphataemia with a mean delta phosphorous of -47% ± 9%. All cats were documented to be hypokalaemic. During hospitalisation, 10/11 cats developed hyperglycaemia and 7/11 cats developed hypoglycaemia. Cardiovascular, gastrointestinal and neurological signs were common. Eight of 11 cats displayed new or progressive neurological deficits after refeeding, including mentation changes and cerebellar dysfunction. All cats became anaemic and seven cats required a blood transfusion. Eight cats survived to discharge after a mean of 14 ± 4 days of hospitalisation. Six cats developed acute kidney injury (AKI; International Renal Interest Society stage 1). The presence of AKI (P = 0.024) was associated with non-survival and maximum bilirubin concentration was significantly higher in non-survivors (P = 0.018). CONCLUSIONS AND RELEVANCE Cats with RS in this cohort had been missing, presumed starved, for more than 3 weeks. In addition to hypophosphataemia and hypokalaemia, altered glucose homeostasis and organ damage involving the liver and kidneys were common. Cats with RS appear to have a good prognosis, but prolonged intensive care is required.
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Affiliation(s)
- Simon Cook
- Department of Clinical Science and Services, The Royal Veterinary College, London, UK
| | - Emily Whitby
- Department of Clinical Science and Services, The Royal Veterinary College, London, UK
| | | | - Georgina Hall
- Department of Clinical Science and Services, The Royal Veterinary College, London, UK
| | - Daniel L Chan
- Department of Clinical Science and Services, The Royal Veterinary College, London, UK
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Yamazaki T, Inada S, Sawada M, Sekine R, Kubota N, Fukatsu K, Yoshiuchi K. Diets with high carbohydrate contents were associated with refeeding hypophosphatemia: A retrospective study in Japanese inpatients with anorexia nervosa. Int J Eat Disord 2021; 54:88-94. [PMID: 33236366 DOI: 10.1002/eat.23416] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Refeeding hypophosphatemia (RH) is a potentially fatal complication in patients with anorexia nervosa (AN), and its dietary preventive strategy is not well established. We aimed to examine the association between carbohydrate content in the diet and the occurrence of RH in inpatients with AN via retrospective medical chart review. METHOD We performed a chart review to collect data of patients with AN hospitalized at the Department of Psychosomatic Medicine of the University of Tokyo Hospital between April 1, 2012, and February 29, 2020. Receiver operating characteristic (ROC) analysis was performed to determine the cutoff point of the percentage of carbohydrate content in the diet for the occurrence of RH. Multivariate logistic regression analysis was performed with occurrence of RH as the dependent variable and the carbohydrate content of more than the identified cutoff point as the independent variable adjusting for the risk factors for RH. RESULTS The percentage of carbohydrate content that is higher than the cutoff point obtained from the ROC analysis (58.4%) was significantly associated with the occurrence of RH, even after adjusting for variables associated with RH in univariate logistic regression analysis (age and body mass index) as well as the average daily calorie intake (odds ratio, 5.37; 95% confidence interval, 1.60-18.1; p = .0066). DISCUSSION We identified that diets with higher carbohydrate contents were associated with RH in inpatients with AN, even after adjusting for known risk factors. Our findings may promote the development of dietary preventive strategies against RH in inpatients with AN.
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Affiliation(s)
- Tadahiro Yamazaki
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuji Inada
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mika Sawada
- Department of Clinical Nutrition Therapy, The University of Tokyo Hospital, Tokyo, Japan
| | - Rie Sekine
- Department of Clinical Nutrition Therapy, The University of Tokyo Hospital, Tokyo, Japan
| | - Naoto Kubota
- Department of Clinical Nutrition Therapy, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuhiko Fukatsu
- Department of Clinical Nutrition Therapy, The University of Tokyo Hospital, Tokyo, Japan
| | - Kazuhiro Yoshiuchi
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Ponzo V, Pellegrini M, Cioffi I, Scaglione L, Bo S. The Refeeding Syndrome: a neglected but potentially serious condition for inpatients. A narrative review. Intern Emerg Med 2021; 16:49-60. [PMID: 33074463 PMCID: PMC7843537 DOI: 10.1007/s11739-020-02525-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022]
Abstract
The Refeeding Syndrome (RFS) is a potentially serious, but still overlooked condition, occurring in individuals who are rapidly fed after a period of severe undernourishment. RFS derives from an abnormal electrolyte and fluid shifts leading to many organ dysfunctions. Symptoms generally appear within 2-5 days of re-feeding and may be absent/mild or severe and life threating, depending on the pre-existing degree of malnutrition and comorbidities. The lack of a standard definition and the nonspecificity of the symptoms make both incidence estimate and diagnosis difficult. In 2020, the American Society for Parenteral and Enteral Nutrition (ASPEN) proposed a unifying definition for the RFS and its severity classification. The awareness of the condition is crucial for identifying patients at risk, preventing its occurrence, and improving the management. The objectives of this narrative review were to summarize the current knowledge and recommendations about the RFS and to provide useful tips to help physicians to recognize and prevent the syndrome.
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Affiliation(s)
- Valentina Ponzo
- Department of Medical Sciences, University of Torino, c.so AM Dogliotti 14, 10126, Turin, Italy
| | - Marianna Pellegrini
- Department of Medical Sciences, University of Torino, c.so AM Dogliotti 14, 10126, Turin, Italy
| | - Iolanda Cioffi
- Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Luca Scaglione
- Internal Medicine Unit, Città della Salute e della Scienza Hospital of Torino, Turin, Italy
| | - Simona Bo
- Department of Medical Sciences, University of Torino, c.so AM Dogliotti 14, 10126, Turin, Italy.
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Coe ME, Castellano L, Elliott M, Reyes J, Mendoza J, Cheney D, Gardner T, Austin JP, Lee CC. Incidence of Refeeding Syndrome in Children With Failure to Thrive. Hosp Pediatr 2020; 10:1096-1101. [PMID: 33168566 DOI: 10.1542/hpeds.2020-0124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine the incidence of refeeding syndrome in otherwise healthy children <3 years of age admitted for failure to thrive (FTT). METHODS A multicenter retrospective cohort study was performed on patients aged ≤36 months admitted with a primary diagnosis of FTT from January 1, 2011, to December 31, 2016. The primary outcome measure was the percentage of patients with laboratory evidence of refeeding syndrome. Exclusion criteria included admission to an ICU, parenteral nutrition, history of prematurity, gastrostomy tube feeds, and any complex chronic conditions. RESULTS Of the 179 patients meeting inclusion criteria, none had laboratory evidence of refeeding syndrome. Of these, 145 (81%) had laboratory work done at the time of admission, and 69 (39%) had laboratory work repeated after admission. A small percentage (6%) of included patients experienced an adverse event due to repeat laboratory draw. CONCLUSIONS In otherwise healthy hospitalized patients <3 years of age with a primary diagnosis of FTT, routine laboratory monitoring for electrolyte derangements did not reveal any cases of refeeding syndrome. More robust studies are needed to determine the safety and feasibility of applying low-risk guidelines to this patient population to reduce practice variability and eliminate unnecessary laboratory evaluation and monitoring.
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Affiliation(s)
- Megan E Coe
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia;
| | - Lucinda Castellano
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Megan Elliott
- Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Joshua Reyes
- Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Joanne Mendoza
- Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Debbie Cheney
- Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Tiffany Gardner
- School of Medicine, Oregon Health & Science University, Portland, Oregon; and
| | - Jared P Austin
- Department of Pediatrics, Oregon Health & Science and University Doernbecher Children's Hospital, Portland, Oregon
| | - Clifton C Lee
- Department of Pediatrics, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
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Jordao AA, Canale A, Brunaldi M, Zucoloto S. Hepatic ballooning degeneration: a new feature of the refeeding syndrome in rats. Clin Exp Hepatol 2020; 6:327-334. [PMID: 33511280 PMCID: PMC7816639 DOI: 10.5114/ceh.2020.102151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/21/2020] [Indexed: 11/17/2022] Open
Abstract
AIM OF THE STUDY Hepatic changes have been described during the refeeding syndrome due to increase in enzymes and hepatomegaly; however, they have not been properly described. Thus, the objective of this study was to investigate the hepatic histological characteristics and biochemical markers of hepatic steatosis in Wistar rats with refeeding syndrome. MATERIAL AND METHODS Thirty male Wistar rats were allocated to one of three groups: C, F or R. The animals from group C received an AIN-93 diet for 96 hours, and were then sacrificed. Animals allocated to group F were fasted for 48 hours and sacrificed. Animals from group R were also fasted for 48 hours, but were refed for another 48 hours, with AIN-93. The liver, blood and epididymal and retroperitoneal fats were collected. RESULTS Data obtained in groups F and R show the changes observed in refeeding syndrome, during starvation and refeeding. The serum glucose, magnesium, potassium and phosphorus, in group F, decreased. There was no evidence of hepatic steatosis. Hypophosphatemia, hypomagnesemia and hypokalemia were also observed in group R, confirming refeeding syndrome. The main histological characteristic, in this group, was the extensive presence of ballooning degeneration. This is the first article that has detected such change in liver structure, due to refeeding syndrome. The possible causes are: retention of sodium, causing whole body edema; and/or dysfunction of the sodium/potassium pump of the hepatocytes, as a result of hypophosphatemia. CONCLUSIONS This is the first description of an animal model of hepatic severe ballooning degeneration induced due to refeeding syndrome.
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Affiliation(s)
- Alceu Afonso Jordao
- Faculty of Medicine of Ribeirão Preto, University of Sao Paulo (USP), Brazil
| | - Amanda Canale
- Faculty of Medicine of Ribeirão Preto, University of Sao Paulo (USP), Brazil
| | - Mariângela Brunaldi
- Faculty of Medicine of Ribeirão Preto, University of Sao Paulo (USP), Brazil
| | - Sergio Zucoloto
- Faculty of Medicine of Ribeirão Preto, University of Sao Paulo (USP), Brazil
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Parker E, Flood V, Halaki M, Wearne C, Anderson G, Gomes L, Clarke S, Wilson F, Russell J, Frig E, Kohn M. Study protocol for a randomised controlled trial investigating two different refeeding formulations to improve safety and efficacy of hospital management of adolescent and young adults admitted with anorexia nervosa. BMJ Open 2020; 10:e038242. [PMID: 33033021 PMCID: PMC7542921 DOI: 10.1136/bmjopen-2020-038242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Providing effective nutritional rehabilitation to patients hospitalised with anorexia nervosa (AN) is challenging, partly due to conservative recommendations that advocate feeding patients at low energy intakes. An 'underfeeding syndrome' can develop when patients are not provided with adequate nutrition during treatment, whereby malnourished patients fail to restore weight in a timely matter, and even lose weight. Of particular concern, the reintroduction of carbohydrate in a starved patient can increase the risk of developing electrolyte, metabolic and organ dysfunction. The proposed trial assesses the efficacy and safety of a lower carbohydrate enteral formula (28% carbohydrate) against a standard enteral formula (54% carbohydrate), in adolescent and young adult patients (aged 15-25 years), hospitalised with AN. METHODS AND ANALYSIS The study employs a double-blind randomised controlled trial design. At admission to hospital, malnourished adolescent and young adults with AN will be randomly allocated to commence feeding on a standard enteral feeding formula (1.5 kcal/mL, 54% carbohydrate) or a lower carbohydrate isocaloric enteral feeding formula (1.5 kcal/mL, 28% carbohydrate). Assessments of nutritional intake, weight and biochemistry (phosphate, magnesium, potassium) will be conducted at baseline and during the first 3 weeks of hospital admission. The primary outcome measure will be incidence of hypophosphatemia. Secondary outcomes include weight gain, oedema, other electrolyte distortion, length of hospital admission, admission to the Intensive Care Unit (ICU) and number of days to reach medical stability, using defined parameters. ETHICS AND DISSEMINATION The protocol was approved by the Western Sydney Local Health District Human Research Ethics Committee and institutional research governance approvals were granted. Written informed consent will be sought prior to study enrolment. Study findings will be widely disseminated through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER Australian New Zealand Clinical Trials Registry (ACTRN12617000342314); Pre-results.
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Affiliation(s)
- Elizabeth Parker
- Department of Dietetics & Nutrition, Westmead Hospital, Westmead, New South Wales, Australia
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Victoria Flood
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Allied Health Research Unit, Western Sydney Local Health District, Westmead Hospital, New South Wales, Australia
| | - Mark Halaki
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christine Wearne
- Department of Medical Psychology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Gail Anderson
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Linette Gomes
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Simon Clarke
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- Centre for Research into Adolescents' Health (CRASH); Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Frances Wilson
- Department of Psychiatry, Westmead Hospital, Westmead, New South Wales, Australia
| | - Janice Russell
- Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- NSW Statewide Eating Disorder Service, Peter Beumont Unit, Professor Marie Bashir Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Elizabeth Frig
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Michael Kohn
- Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- Centre for Research into Adolescents' Health (CRASH); Department of Adolescent & Young Adult Medicine, Westmead Hospital, Westmead, New South Wales, Australia
- Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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Yakubovich D, Strauss T, Ohana D, Taran C, Snapiri O, Karol DL, Starez-Chaham O, Kochavi B, Tsur A, Morag I. Factors associated with early phosphate levels in preterm infants. Eur J Pediatr 2020; 179:1529-1536. [PMID: 32248319 DOI: 10.1007/s00431-020-03622-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 12/01/2022]
Abstract
To investigate perinatal factors and early morbidities associated with early serum phosphate (sPhos) levels in a cohort of preterm infants. Retrospective data were obtained from the medical records of a cohort of 454 infants born at < 32 weeks gestational age. Serum phosphate levels were directly associated with gestational age, body weight z-score, and Apgar scores and inversely associated with timing of enteral nutrition initiation and diet consisting of mostly breast milk. Maternal hypertension, lactate levels, early symptomatic hypotension, and total protein supplemented on days 1 to 3 were also inversely associated with sPhos. Morbidities that were found to be associated with sPhos did not persist after adjustment for confounding factors.Conclusions: We report a novel association between early sPhos and timing and content of enteral nutrition, as well as with the early neonatal hemodynamic condition of preterm infants. This information may help identify infants at risk for low sPhos and aid in the nutritional strategy utilized in these patients. This study did not identify early morbidities associated with sPhos. What is Known: • High initial amino acid intake is associated with increased risk of Refeeding like syndrome and hypophosphatemia, among preterm infants. What is New: • Early enteral nutrition, starting within the first 72 h of life, is associated with higher serum phosphate (sPhos) compared to nothing per os (NPO). • sPhos was not associated with early adverse neonatal outcomes.
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Affiliation(s)
- Daniel Yakubovich
- Department of Pediatrics, Schneider Children's Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Tzipi Strauss
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.,Department of Pediatrics, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Dror Ohana
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Camelia Taran
- Department of Pediatrics, Grigore Alexandrescu Emergency Clinical Hospital for Children in Bucharest, București, Romania
| | - Ori Snapiri
- Department of Pediatrics, Schneider Children's Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | | | - Orna Starez-Chaham
- Department of Neonatology, Soroka Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Briggite Kochavi
- Department of Pediatrics, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Abraham Tsur
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.,Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA.,Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Iris Morag
- Sackler School of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel. .,Department of Pediatrics, Shamir Medical Center, 70300, Zerifin, Israel.
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Blaauw R, Osland E, Sriram K, Ali A, Allard JP, Ball P, Chan LN, Jurewitsch B, Logan Coughlin K, Manzanares W, Menéndez AM, Mutiara R, Rosenfeld R, Sioson M, Visser J, Berger MM. Parenteral Provision of Micronutrients to Adult Patients: An Expert Consensus Paper. JPEN J Parenter Enteral Nutr 2020; 43 Suppl 1:S5-S23. [PMID: 30812055 DOI: 10.1002/jpen.1525] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/04/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Micronutrients, an umbrella term used to collectively describe vitamins and trace elements, are essential components of nutrition. Those requiring alternative forms of nutrition support are dependent on the prescribed nutrition regimen for their micronutrient provision. The purpose of this paper is to assist clinicians to bridge the gap between the available guidelines' recommendations and their practical application in the provision of micronutrients via the parenteral route to adult patients. METHODS Based on the available evidenced-based literature and existing guidelines, a panel of multidisciplinary healthcare professionals with significant experience in the provision of parenteral nutrition (PN) and intravenous micronutrients developed this international consensus paper. RESULTS The paper addresses 14 clinically relevant questions regarding the importance and use of micronutrients in various clinical conditions. Practical orientation on how micronutrients should be prescribed, administered, and monitored is provided. CONCLUSION Micronutrients are a critical component to nutrition provision and PN provided without them pose a considerable risk to nutrition status. Obstacles to their daily provision-including voluntary omission, partial provision, and supply issues-must be overcome to allow safe and responsible nutrition practice.
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Affiliation(s)
- Renée Blaauw
- Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Emma Osland
- Department of Nutrition and Dietetics, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Krishnan Sriram
- US Department of Veterans Affairs, Regional Tele-ICU System (VISN 23), Hines, Illinois, USA
| | - Azmat Ali
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Johane P Allard
- Division of Gastroenterology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Patrick Ball
- School of Pharmacy, University of Wolverhampton, Wolverhampton, UK
| | - Lingtak-Neander Chan
- Department of Pharmacy School of Pharmacy, and Graduate Program in Nutritional Sciences, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Brian Jurewitsch
- Specialized Complex Care Program, St. Michael's Hospital, Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Kathleen Logan Coughlin
- Center for Human Nutrition, Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - William Manzanares
- Department of Critical Care, Faculty of Medicine. Hospital de Clínicas, Universidad de la República (UdelaR), Montevideo, Uruguay
| | | | - Rina Mutiara
- Pharmacy Department, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Ricardo Rosenfeld
- Nutrition Support Department, Casa de Saude Sao Jose, Associacao Congregacao de Santa Catarina, Rio de Janeiro, Brazil
| | - Marianna Sioson
- Section of Nutrition, Department of Medicine, The Medical City Hospital, Pasig City, Metro Manila, Philippines
| | - Janicke Visser
- Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mette M Berger
- Faculty of Biology and Medicine, Service of Intensive Care Medicine & Burns, University of Lausanne Hospitals (CHUV), Lausanne, Switzerland
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Eriksen MK, Baunwall SMD, Lal S, Dahlerup JF, Hvas CL. Hypophosphatemia in a Specialized Intestinal Failure Unit: An Observational Cohort Study. JPEN J Parenter Enteral Nutr 2020; 45:1259-1267. [PMID: 32841404 PMCID: PMC8451901 DOI: 10.1002/jpen.2006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/28/2020] [Accepted: 08/17/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Patients with intestinal failure (IF) are prone to hypophosphatemia and shifts in magnesium and potassium levels. Although these shifts are often attributed to refeeding syndrome (RFS), the incidence of electrolyte shifts among patients with IF is unknown. We evaluated the occurrence of hypophosphatemia and other electrolyte shifts according to the functional and pathophysiological IF classifications. METHODS We consecutively included all patients' first admission to an IF unit from 2013 to 2017. Electrolyte shifts were defined as severe hypophosphatemia <0.6 mmol/L (mM) or any 2 other shifts below reference range, comprising hypomagnesemia <0.75 mM, hypophosphatemia <0.8 mM, or hypokalemia <3.5 mM. Outcomes included length of stay, central line-associated bloodstream infection, and other infections. Mortality was evaluated 6 months after discharge. RESULTS Of 236 patients with IF, electrolyte shifts occurred in 99 (42%), and 127 (54%) of these patients received intravenous supplementation with either phosphate, magnesium, or potassium. In patients who started parenteral nutrition, up to 62% of early-onset shifts (<5 days) related to refeeding, and up to 63% of late-onset shifts (≥5 days) could be ascribed to infections. Derangements occurred in 7 (18%) with type 1 IF, 53 (43%) with type 2 IF, and 39 (53%) readmitted patients with type 3 IF. Of 133 patients with IF secondary to short-bowel syndrome, 65 (49%) developed shifts. CONCLUSION In patients with IF, electrolyte shifts are frequent but not always due to RFS. Electrolyte shifts are common in patients with type 2 and those readmitted with type 3 IF.
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Affiliation(s)
| | | | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Jens Frederik Dahlerup
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Lodberg Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Meira APC, Santos COD, Lucho CLC, Kasmirscki C, Silva FM. Refeeding Syndrome in Patients Receiving Parenteral Nutrition Is Not Associated to Mortality or Length of Hospital Stay: A Retrospective Observational Study. Nutr Clin Pract 2020; 36:673-678. [PMID: 32744370 DOI: 10.1002/ncp.10563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Refeeding syndrome (RS) is characterized by severe electrolyte derangement that may be associated with worse clinical outcomes in hospitalized patients. In this study, we aim to assess the incidence of RS in inpatients receiving parenteral nutrition (PN) and its possible association with the length of hospital stay (LHS) and mortality. METHODS We conducted a historical cohort study involving adults receiving PN, monitored by a nutrition therapy team in a Brazilian public hospital. Data collection was made from electronic records. We assessed the presence of RS after PN therapy was initiated. The amount of energy delivered within 72 hours of PN, LHS, and mortality were compared between patients with and without RS. RESULTS One-hundred ninety-seven patients (aged 57.7 ± 14.1 years; 55.7% men) were followed for a median of 51 days. The incidence of RS was equal to 25.4%. The adequacy of energy delivered in relation to energy requirements within 72 hours (69.4% ± 29.3% vs 61.8% ± 21.6%) was higher in patients with RS than in those without RS (P = .054). The incidence of death was 55.3% and did not differ between groups. The median of LHS was equal to 51.0 (32.0-83.0) days, and it also did not differ between patients with and without RS. CONCLUSION RS was identified in 25% of patients receiving PN, but it was not associated to mortality and LHS, even when energy delivery was considered in combination to RS.
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Affiliation(s)
- Ana Paula Corrêa Meira
- Enteral and Parenteral Nutrition Therapy Team in Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
| | | | | | - Cristine Kasmirscki
- Enteral and Parenteral Nutrition Therapy Team in Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil
| | - Flávia Moraes Silva
- Nutrition Department and Postgraduate Program in Nutrition Science in Federal University of Health Science of Porto Alegre, Porto Alegre, Brazil
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da Silva JSV, Seres DS, Sabino K, Adams SC, Berdahl GJ, Citty SW, Cober MP, Evans DC, Greaves JR, Gura KM, Michalski A, Plogsted S, Sacks GS, Tucker AM, Worthington P, Walker RN, Ayers P. ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract 2020; 35:178-195. [DOI: 10.1002/ncp.10474] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
| | - David S. Seres
- Columbia University Irving Medical Center New York New York USA
| | - Kim Sabino
- Saint Francis Hospital and Medical Center Hartford Connecticut USA
| | | | - Gideon J. Berdahl
- School of Pharmacy, University of Mississippi Jackson Mississippi USA
| | | | - M. Petrea Cober
- Akron Children's Hospital Akron Ohio USA
- Northeast Ohio Medical University Rootstown Ohio USA
| | - David C. Evans
- Ohio Health Trauma and Surgical Services Columbus Ohio USA
| | - June R. Greaves
- Coram CVS Speciality Infusion Services Northbrook Illinois USA
| | | | - Austin Michalski
- Patient Food and Nutrition ServicesMichigan Medicine Ann Arbor Michigan USA
| | - Stephen Plogsted
- Nutrition Support ServiceNationwide Children's Hospital Columbus Ohio USA
| | - Gordon S. Sacks
- Medical AffairsFresenius Kabi USA LLC Lake Zurich Illinois USA
| | - Anne M. Tucker
- Critical Care and Nutrition SupportUniversity of Texas M D Anderson Cancer Center Houston Texas USA
| | | | - Renee N. Walker
- Michael E. DeBakey Veterans Affairs Medical Center Houston Texas USA
| | - Phil Ayers
- Clinical Pharmacy ServicesMississippi Baptist Medical Center Jackson Mississippi USA
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Abstract
PURPOSE OF REVIEW The aim of this review is to provide a brief overview of the refeeding syndrome, to discuss more recent advice on diagnosis and treatment, and to raise awareness of this still poorly understood metabolic condition. RECENT FINDINGS To date, evidence regarding the refeeding syndrome has been very limited. A number of reviews and case reports exist, but only a few are randomized trials. Recently, it has been shown that the vast majority of physicians are unaware of this metabolic condition. Precise guidelines for diagnosis and treatment of this syndrome were lacking for a long time. Now, a consensus statement is available, providing guidance from experts in the field on the management of patients at increased risk of refeeding syndrome (RFS) receiving nutritional therapy. SUMMARY Due to the increased use of nutritional therapy in inpatient settings, physicians should be aware of possible side effects, particularly in connection with the refeeding syndrome. In this context, every patient should undergo a risk assessment for refeeding syndrome and stratification before starting nutritional therapy. For patients at high risk, nutritional support should be administered with adapted energy and fluid support during the replenishment phase. In addition, the occurrence of RFS during nutritional therapy must be continuously evaluated, and appropriate steps taken if necessary.
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Second-Trimester Fetal Loss in a Patient With Hyperemesis Gravidarum Complicated by Refeeding Syndrome. Obstet Gynecol 2020; 133:1167-1170. [PMID: 31135730 DOI: 10.1097/aog.0000000000003276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Refeeding syndrome is a rare constellation of electrolyte abnormalities after reintroduction of glucose during an adaptive state of starvation and malnutrition, resulting in fluid shifts, end-organ damage, and, potentially, death. We present a case of fetal death in a patient with hyperemesis gravidarum complicated by refeeding syndrome. CASE A 32-year-old obese, multigravid patient was admitted at 16 weeks of gestation with hyperemesis gravidarum and laboratory abnormalities concerning for refeeding syndrome after consuming a sugar-rich beverage. She was admitted to the hospital for electrolyte and fluid repletion; however, on hospital day 2, fetal death was diagnosed. CONCLUSION Refeeding syndrome is a potentially fatal complication of hyperemesis gravidarum. Caution should be taken when reintroducing glucose during prolonged states of malnutrition to prevent the development of refeeding syndrome.
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Szeja N, Grosicki S. Refeeding syndrome in hematological cancer patients - current approach. Expert Rev Hematol 2020; 13:201-212. [PMID: 32028807 DOI: 10.1080/17474086.2020.1727738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: According to estimates based on the GLOBOCAN database of the International Agency for Research on Cancer, in 2018 alone, 18 100 000 cancers were globally diagnosed. Importantly, the majority of cancer patients experience unintended weight loss that leads to many adverse clinical consequences, including malnutrition and cancer cachexia. At the same time, each nutritional intervention must be carried out individually, as it can lead to critical complications, resulting in a threat to the health and life of the cachectic patient. An example of this type of risk is refeeding syndrome.Areas covered: Three factors seem to be crucial in this case: early identification of patients at risk of malnutrition, the introduction of an individualized diet regimen and constant monitoring of nutritional intervention. It seems equally important to spread awareness about the possibility of refeeding syndrome and knowledge about its patomechanisms and consequences among medical staff. This should lead to minimizing the risk of refeeding syndrome.Expert opinion: It should be noted that current guidelines on the pathogenesis, risk factors and methods of prevention and treatment of refeeding syndrome require further modifications, that would harmonize the management regimen in both prevention and therapy of refeeding syndrome.
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Affiliation(s)
- Nicola Szeja
- Department of Hematology and Cancer Prevention in Chorzów, Faculty of Public Health in Bytom, Medical University of Silesia in Katowice, Katowice, Poland
| | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention in Chorzów, Faculty of Public Health in Bytom, Medical University of Silesia in Katowice, Katowice, Poland
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Friedli N, Baumann J, Hummel R, Kloter M, Odermatt J, Fehr R, Felder S, Baechli V, Geiser M, Deiss M, Tribolet P, Gomes F, Mueller B, Stanga Z, Schuetz P. Refeeding syndrome is associated with increased mortality in malnourished medical inpatients: Secondary analysis of a randomized trial. Medicine (Baltimore) 2020; 99:e18506. [PMID: 31895785 PMCID: PMC6946353 DOI: 10.1097/md.0000000000018506] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/18/2019] [Accepted: 11/26/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Whether the occurrence of refeeding syndrome (RFS), a metabolic condition characterized by electrolyte shifts after initiation of nutritional therapy, has a negative impact on clinical outcomes remains ill-defined. We prospectively investigated a subgroup of patients included in a multicentre, nutritional trial (EFFORT) for the occurrence of RFS. METHODS In this secondary analysis of a randomized-controlled trial investigating the effects of nutritional support in malnourished medical inpatients, we prospectively screened patients for RFS and classified them as "RFS confirmed" and "RFS not confirmed" based on predefined criteria (i.e. electrolyte shifts, clinical symptoms, clinical context, and patient history). We assessed associations of RFS and mortality within 180 days (primary endpoint) and other secondary endpoints using multivariable regression analysis. RESULTS Among 967 included patients, RFS was confirmed in 141 (14.6%) patients. Compared to patients with no evidence for RFS, patients with confirmed RFS had significantly increased 180-days mortality rates (42/141 (29.8%) vs 181/826 (21.9%), adjusted odds ratio (OR) 1.53 (95% CI 1.02 to 2.29), P < .05). Patients with RFS also had an increased risk for ICU admission (6/141 (4.3%) vs 13/826 (1.6%), adjusted OR 2.71 (95% CI 1.01 to 7.27), P < .05) and longer mean length of hospital stays (10.5 ± 6.9 vs 9.0 ± 6.6 days, adjusted difference 1.57 days (95% CI 0.38-2.75), P = .01). CONCLUSION A relevant proportion of medical inpatients with malnutrition develop features of RFS upon hospital admission, which is associated with long-term mortality and other adverse clinical outcomes. Further studies are needed to develop preventive strategies for RFS in this patient population.
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Affiliation(s)
- Natalie Friedli
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | | | | | | | - Jonas Odermatt
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Rebecca Fehr
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Susan Felder
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Valerie Baechli
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Martina Geiser
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Manuela Deiss
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
| | - Pascal Tribolet
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
- Department of Health Professions Bern, University of Applied Sciences, Bern, Switzerland
| | - Filomena Gomes
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
- The New York Academy of Sciences, NY, USA
| | - Beat Mueller
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
- Medical Faculty of the University of Basel, Basel
| | - Zeno Stanga
- Department of Endocrinology, Diabetes, Nutritional Medicine and Metabolism, Bern University Hospital, and University of Bern, Switzerland
| | - Philipp Schuetz
- Medical University Department, Clinic for Endocrinology/Metabolism/Clinical Nutrition, Kantonsspital Aarau, Aarau
- Medical Faculty of the University of Basel, Basel
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Reber E, Friedli N, Vasiloglou MF, Schuetz P, Stanga Z. Management of Refeeding Syndrome in Medical Inpatients. J Clin Med 2019; 8:jcm8122202. [PMID: 31847205 PMCID: PMC6947262 DOI: 10.3390/jcm8122202] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/05/2019] [Accepted: 12/11/2019] [Indexed: 12/14/2022] Open
Abstract
Refeeding syndrome (RFS) is the metabolic response to the switch from starvation to a fed state in the initial phase of nutritional therapy in patients who are severely malnourished or metabolically stressed due to severe illness. It is characterized by increased serum glucose, electrolyte disturbances (particularly hypophosphatemia, hypokalemia, and hypomagnesemia), vitamin depletion (especially vitamin B1 thiamine), fluid imbalance, and salt retention, with resulting impaired organ function and cardiac arrhythmias. The awareness of the medical and nursing staff is often too low in clinical practice, leading to under-diagnosis of this complication, which often has an unspecific clinical presentation. This review provides important insights into the RFS, practical recommendations for the management of RFS in the medical inpatient population (excluding eating disorders) based on consensus opinion and on current evidence from clinical studies, including risk stratification, prevention, diagnosis, and management and monitoring of nutritional and fluid therapy.
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Affiliation(s)
- Emilie Reber
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, and University of Bern, 3010 Bern, Switzerland;
- Correspondence:
| | - Natalie Friedli
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland; (N.F.); (P.S.)
| | - Maria F. Vasiloglou
- AI in Health and Nutrition Laboratory, ARTORG Center for Biomedical Engineering Research, University of Bern, 3008 Bern, Switzerland;
| | - Philipp Schuetz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland; (N.F.); (P.S.)
- Medical Faculty of the University of Basel, 4056 Basel, Switzerland
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, Bern University Hospital, and University of Bern, 3010 Bern, Switzerland;
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Yamazaki T, Inada S, Yoshiuchi K. Body mass index cut-off point associated with refeeding hypophosphatemia in adults with eating disorders. Int J Eat Disord 2019; 52:1322-1325. [PMID: 31584711 DOI: 10.1002/eat.23177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/29/2019] [Accepted: 09/12/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Refeeding hypophosphatemia (RH) is a life-threatening complication in underweight patients with eating disorders (EDs). Although a lower body mass index (BMI) has been reported as a risk factor for RH, the exact BMI cut-off point is not known. Herein, we aimed to identify the optimal BMI cut-off point for RH in adults with EDs. METHOD The medical charts of Japanese inpatients with EDs at our hospital between April 1, 2012 and March 31, 2017 were retrospectively reviewed. The optimal BMI cut-off point for RH was determined via receiver operating characteristic analysis. Logistic regression analysis was subsequently performed to assess the association between RH and the BMI cut-off point after adjusting for the propensity score, which was based on known risk factors for RH. RESULTS The optimal BMI cut-off point was identified as 12.6 kg/m2 . A BMI lower than the cut-off point significantly correlated with the occurrence of RH after adjusting for the propensity score. DISCUSSION The optimal BMI cut-off point for the occurrence of RH was 12.6 kg/m2 in adults with EDs. The findings of the present study may facilitate clinical decision making and early identification of patients who require prophylactic treatment for RH.
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Affiliation(s)
- Tadahiro Yamazaki
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shuji Inada
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiro Yoshiuchi
- Department of Stress Sciences and Psychosomatic Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Kondo T, Nakamura M, Kawashima J, Matsumura T, Ohba T, Yamaguchi M, Katabuchi H, Araki E. Hyperemesis gravidarum followed by refeeding syndrome causes electrolyte abnormalities induced rhabdomyolysis and diabetes insipidus. Endocr J 2019; 66:253-258. [PMID: 30700639 DOI: 10.1507/endocrj.ej18-0496] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Although hyperemesis gravidarum (HG), an extreme form of morning sickness, is a common complication during pregnancy, HG associated simultaneous onset of rhabdomyolysis and diabetes insipidus due to electrolyte abnormalities are rare. A 34-year-old woman with severe HG at 17 weeks of gestation complicated with appetite loss, weight reduction by 17 kg, general fatigue, myalgia, weakness and polyuria was identified to have simultaneous hypophosphatemia (1.6 mg/dL) and hypokalemia (2.0 mEq/L). Appetite recovery and the improvement of the hypophosphatemia (3.2 mg/dL) were observed prior to the first visit to our department. At the admission, she presented polyuria around 7,000~8,000 mL/day with impaired concentrating activity (U-Osm 185 mOsm/L), and abnormal creatine kinase elevation (4,505 U/L). The electrolyte disturbances and physio-metabolic abnormalities in undernourished state due to HG let us diagnose this case as refeeding syndrome (RFS). In this case, abnormal loss by vomiting, insufficient intake and previous inappropriate fluid infusion as well as the development of RFS may accelerate the severity of hypokalemia due to HG. Thus, as her abnormalities were considered as results of rhabdomyolysis and diabetes insipidus due to severe HG associated hypokalemia based on RFS, oral supplementation of potassium chloride was initiated. After 6 days of potassium supplementation, her symptoms and biochemical abnormalities were completely resolved. Severe HG followed by RFS can be causes of electrolyte abnormalities and subsequent complications, including rhabdomyolysis and renal diabetes insipidus. Appropriate diagnosis and prompt interventions including adequate nutrition are necessary to prevent electrolyte imbalance induced cardiac, neuromuscular and/or renal complications.
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Affiliation(s)
- Tatsuya Kondo
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Miwa Nakamura
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Junji Kawashima
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Takeshi Matsumura
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Takashi Ohba
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Munekage Yamaguchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Hidetaka Katabuchi
- Department of Obstetrics and Gynecology, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
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Fuentes E, Yeh DD, Quraishi SA, Johnson EA, Kaafarani H, Lee J, King DR, DeMoya M, Fagenholz P, Butler K, Chang Y, Velmahos G. Hypophosphatemia in Enterally Fed Patients in the Surgical Intensive Care Unit: Common but Unrelated to Timing of Initiation or Aggressiveness of Nutrition Delivery. Nutr Clin Pract 2018; 32:252-257. [PMID: 29927524 DOI: 10.1177/0884533616662988] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Hypophosphatemia has been associated with refeeding malnourished patients, but its clinical significance is unclear. We investigated the incidence of refeeding hypophosphatemia (RH) in the surgical intensive care unit (SICU) and its association with early enteral nutrition (EN) administration and clinical outcomes. METHODS We performed a retrospective review of a 2-year database of patients receiving EN in the SICU. RH was defined as a post-EN phosphorus (PHOS) level decrement of >0.5 mg/dL to a nadir <2.0 mg/dL within 8 days from EN initiation. We investigated the risk factors for RH and examined its association with clinical outcomes using multivariable regression analyses. RESULTS In total, 213 patients comprised our analytic cohort. Eighty-three of 213 (39%) individuals experienced RH and 43 of 130 (33%) of the remaining patients experienced non-RH hypophosphatemia (nadir PHOS level <2.0 mg/dL). Overall, there was a total 59% incidence of hypophosphatemia of any cause (N = 126). Nutrition parameters did not differ between groups; most patients were initiated on EN within 48 hours of SICU admission, and timing of EN initiation was not a significant predictor for the development of RH. The median hospital length of stay (LOS) was 21 and 24 days for those with and without RH, respectively (P = .79); RH remained a nonsignificant predictor for hospital LOS in the multivariable analysis. CONCLUSIONS RH is common in the SICU but is not related to timing or amount of EN. Hypophosphatemia is also common in the critically ill, but regardless of etiology, it was not found to be a predictor of worse clinical outcomes.
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Affiliation(s)
- Eva Fuentes
- Department of Surgery, Division of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - D Dante Yeh
- Department of Surgery, Division of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sadeq A Quraishi
- Department of Surgery, Division of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Haytham Kaafarani
- Department of Surgery, Division of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jarone Lee
- Department of Surgery, Division of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David R King
- Department of Surgery, Division of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marc DeMoya
- Department of Surgery, Division of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Fagenholz
- Department of Surgery, Division of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathryn Butler
- Department of Surgery, Division of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yuchiao Chang
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
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Oudman E, Wijnia JW, Oey MJ, van Dam MJ, Postma A. Preventing Wernicke's encephalopathy in anorexia nervosa: A systematic review. Psychiatry Clin Neurosci 2018; 72:774-779. [PMID: 29984541 DOI: 10.1111/pcn.12735] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/21/2018] [Accepted: 07/03/2018] [Indexed: 12/12/2022]
Abstract
Anorexia nervosa (AN) is a common eating disorder that affects 2.9 million people worldwide. Not eating a balanced diet or fasting can cause neurological complications after severe vitamin B1 malnourishment, although the precise signs and symptoms of Wernicke's encephalopathy (WE) are not clear. Our aim was to review the signs and symptoms of WE in patients with AN. We searched MEDLINE, EMBASE, Scopus, and PiCarta on all case descriptions of WE following AN. All case descriptions of WE in AN, irrespective of language, were included. Twelve WE cases were reviewed, suggesting that WE following AN is still a relatively rare neuropsychiatric disorder. WE is characterized by a triad of: mental status change, ocular signs, and ataxia. In alcoholism, this triad is present in 16% of cases, but eight out of 12 AN cases presented themselves with a full triad of symptomatology. Importantly, patients often had a more complex triad than has been previously described, involving vertigo, diplopia, and the consequences of refeeding syndrome. The development of a full triad and additional symptomatology suggests a late recognition of signs and symptoms of WE in AN. A complicating factor is the overlap between symptoms of thiamine deficiency and the symptoms of WE. Specifically, patients who show rapid weight loss are vulnerable for the development of WE. Eating disorders, such as AN, can lead to WE. Prophylactic thiamine checks and treatment in patients with AN are relevant, and in case of suspicion of WE, adequate parenteral thiamine supplementation is necessary.
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Affiliation(s)
- Erik Oudman
- Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, The Netherlands.,Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
| | - Jan W Wijnia
- Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, The Netherlands.,Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
| | - Misha J Oey
- Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, The Netherlands.,Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
| | - Mirjam J van Dam
- Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, The Netherlands.,Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
| | - Albert Postma
- Experimental Psychology, Helmholtz Institute, Utrecht University, Utrecht, The Netherlands.,Korsakoff Center Slingedael, Lelie Care Group, Rotterdam, The Netherlands
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Friis H, Range NS, Changalucha J, PrayGod G, Jeremiah K, Faurholt-Jepsen D, Krarup HB, Andersen AB, Kæstel P, Filteau S. HIV, TB, inflammation and other correlates of serum phosphate: A cross-sectional study. Clin Nutr ESPEN 2018; 27:38-43. [PMID: 30144891 DOI: 10.1016/j.clnesp.2018.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 06/05/2018] [Accepted: 07/14/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND There is little information about serum phosphate levels among patients with pulmonary tuberculosis (TB) and HIV infection. OBJECTIVE We aimed to assess the role of TB, HIV, inflammation and other correlates on serum phosphate levels. METHODS A cross-sectional study was conducted among TB patients and age- and sex-matched non-TB controls. Pulmonary TB patients were categorized as sputum -negative and -positive, based on culture. Age- and sex-matched non-TB controls were randomly selected among neighbours to sputum-positive TB patients. Data on age, sex, alcohol and smoking habits were obtained. HIV status, serum phosphate, and the acute phase reactants C-reactive protein (serum CRP) and α1-acid glycoprotein (serum AGP) were determined. Linear regression analysis was used to identify correlates of serum phosphate. RESULTS Of 1605 participants, 355 (22.1%) were controls and 1250 (77.9%) TB patients, of which 9.9% and 50.4% were HIV-infected. Serum phosphate was determined before start of TB treatment in 44%, and 1-14 days after start of treatment in 56%. Serum phosphate was up to 0.10 mmol/L higher 1-3 days after start of TB treatment, and lowest 4 days after treatment, after which it increased. In multivariable analysis, TB patients had 0.09 (95% CI: 0.05; 0.13) mmol/L higher serum phosphate than controls, and those with HIV had 0.05 (95% CI: 0.01; 0.08) mmol/L higher levels than those without. Smoking was also a positive correlate of serum phosphate, whereas male sex and age were negative correlates. CONCLUSION While HIV and TB are associated with higher serum phosphate, our data suggest that TB treatment is followed by transient reductions in serum phosphate, which may reflect hypophosphataemia in some patients.
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Affiliation(s)
- H Friis
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Denmark.
| | - N S Range
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - J Changalucha
- National Institute for Medical Research, Mwanza Medical Research Centre, NIMR, Mwanza, Tanzania
| | - G PrayGod
- National Institute for Medical Research, Mwanza Medical Research Centre, NIMR, Mwanza, Tanzania
| | - K Jeremiah
- National Institute for Medical Research, Mwanza Medical Research Centre, NIMR, Mwanza, Tanzania
| | - D Faurholt-Jepsen
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Denmark
| | - H B Krarup
- Molecular Diagnostics, Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
| | - A B Andersen
- Department of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark
| | - P Kæstel
- Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Denmark
| | - S Filteau
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Aubry E, Friedli N, Schuetz P, Stanga Z. Refeeding syndrome in the frail elderly population: prevention, diagnosis and management. Clin Exp Gastroenterol 2018; 11:255-264. [PMID: 30022846 PMCID: PMC6045900 DOI: 10.2147/ceg.s136429] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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.
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Affiliation(s)
- Emilie Aubry
- Department for Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Bern, Switzerland,
| | - Natalie Friedli
- Medical University Department, Clinic for Endocrinology, Diabetes, Metabolism and Clinical Nutrition, Kantonsspital Aarau, and Medical Faculty of the University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Clinic for Endocrinology, Diabetes, Metabolism and Clinical Nutrition, Kantonsspital Aarau, and Medical Faculty of the University of Basel, Basel, Switzerland
| | - Zeno Stanga
- Department for Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Bern University Hospital and University of Bern, Bern, Switzerland,
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Day AL, Morgan SL, Saag KG. Hypophosphatemia in the setting of metabolic bone disease: case reports and diagnostic algorithm. Ther Adv Musculoskelet Dis 2018; 10:151-156. [PMID: 30023010 DOI: 10.1177/1759720x18779761] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 05/08/2018] [Indexed: 12/14/2022] Open
Abstract
Osteoporosis is the most commonly encountered metabolic bone disease, and metabolic bone-disease clinics have been established to assist in the diagnosis and treatment of uncommon causes of low bone-mineral density. Hypophosphatemia leading to metabolic bone disease may be encountered, and an understanding of phosphate homeostasis can aid in the diagnosis. Two cases of hypophosphatemia leading to low bone-mineral densities were seen at the University of Alabama at Birmingham Osteoporosis Clinic. We developed a diagnostic algorithm, and the laboratory values of each patient were tested with the algorithm. The algorithm, incorporating the use of a spot urine phosphate and spot urine creatinine level at the time of initial serum metabolic profile evaluation, accurately determined the cause of hypophosphatemia in each case.
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Affiliation(s)
- Alvin Lee Day
- University of Alabama at Birmingham, Division of Clinical Immunology and Rheumatology, 1720 2nd Avenue South, FOT 839, Birmingham, AL 35294, USA
| | - Sarah L Morgan
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth G Saag
- University of Alabama at Birmingham, Birmingham, AL, USA
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Nasir M, Zaman BS, Kaleem A. What a Trainee Surgeon Should Know About Refeeding Syndrome: A Literature Review. Cureus 2018; 10:e2388. [PMID: 29850383 PMCID: PMC5973501 DOI: 10.7759/cureus.2388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Refeeding syndrome (RFS) is potentially fatal, yet there is limited understanding regarding its management among general surgeons due in part to a lack of universally accepted guidelines for RFS diagnosis. The aim of this review is to equip general surgery trainees with the essentials of RFS including a review of the National Institute for Health and Care Excellence (NICE) best practice guidelines for RFS. We used the keywords "refeeding", "syndrome", and "hypophosphatemia" to search PubMed, Embase, and Medline databases. We reviewed approximately 130 indexed papers for relevance. Having profound knowledge of nutritional needs in critically ill patients will help trainee surgeons prevent illnesses in the spectrum of RFS, and, over time, this would immensely contribute to reducing the morbidity and mortality associated with RFS.
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Affiliation(s)
- Muneeba Nasir
- Mayo Hospital, King Edward Medical University, Lahore, PAK
| | - Balakh S Zaman
- Mayo Hospital, King Edward Medical University, Lahore, PAK
| | - Ahmad Kaleem
- Mayo Hospital, King Edward Medical University, Lahore, PAK
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