Refeeding and metabolic syndromes: two sides of the same coin

[Intravenous glucose infusion may have caused refeeding syndrome in a patient with advanced amyotrophic lateral sclerosis]

We present the case of a 69-year-old woman who underwent tracheostomy for advanced amyotrophic lateral sclerosis. The patient was treated with furosemide for leg edema. Body mass index was stable at 21.5 ‍kg/m2. The patient was admitted to our hospital after vomiting because of biliary infection. Fluid therapy with 286 ‍kcal/day of glucose was administered, followed by acute deterioration, including tachycardia (120 bpm), glucose intolerance, abdominal pain, hypophosphatemia (required intravenous phosphate supply; 60 ‍mmol/day), and hypokalemia (required intravenous potassium supply; 60 mEq/day). Refeeding syndrome was suspected, and the patient recovered with adjustments in serum electrolyte levels. We demonstrated that glucose infusion can cause refeeding syndrome in patients with advanced amyotrophic lateral sclerosis without low nutritional intake.

A randomized multi-arm open labelled comparative clinical trial report of Pankajakasthuri DiabetEaze powder, a novel polyherbal formulation on the nutritional management and glycemic control in type 2 diabetic and prediabetic patients

Background and aims

Recently Diabetes Mellitus (DM) has been associated with heightened susceptibility to malnutrition, suggesting that augmenting nutritional intake stands out as a potent therapeutic strategy for addressing malnutrition in individuals with DM. The aim of this clinical investigation was to evaluate the effect of DiabetEaze powder, a polyherbal nutritional formulation developed by us for nutritional management and glycaemic control, on patients with diabetic and prediabetic conditions.

Methods

A total of 143 type II diabetic (T2D) patients who were managing their diabetic condition through modern medicine, AYUSH medicine, lifestyle modification and 68 pre-diabetic patients, aged between 40 and 65 years, were randomly assigned into six groups: control, modern, AYUSH, lifestyle, prediabetic control and prediabetic trial. The treatment groups were administered 5 g of DiabetEaze powder two times a day after food for 6 months. Microminerals, vitamins, glycaemic parameters, Quality of Life (QoL), hematology, lipid profiles, Renal Function Test (RFT) and Liver Function Test (LFL) parameters, and electrolytes were evaluated at Day 0, Day 90, and Day 180.

Results

Out of 211 enrolled patients, 189 individuals successfully completed the entire 180-day duration of the study, indicating a retention rate of approximately 89.6 %. In our study, we observed a statistically significant elevation in the levels of vitamin D, B2, and B6 across all treatment groups. Besides, the treatment groups displayed a notable increase in zinc and manganese levels compared to the other minerals tested. Notably, the treatment groups demonstrated distinct mineral and vitamin profiles. In terms of metabolic markers, significant reductions in Fasting Blood Sugar (FBS)/Post Prandial Blood Sugar (PPBS) were observed across the modern, AYUSH, and lifestyle groups, while the modern group also showed a marked decrease in glycated haemoglobin (HbA1c) levels. Furthermore, overall QoL among the tested groups was also statistically significant. The consistent maintenance of normal LFT and RFT parameters and electrolyte levels across trial groups throughout the study duration indicates that the supplement does not induce liver toxicity or negatively impact hepatic function.

Conclusion

In conclusion, the nutrients present in the DiabetEaze powder contribute to the effective management of nutritional status in diabetic people and thus effectively reduce sugar spikes by regulating PPBS and HbA1c levels, which is a critical aspect of its role in diabetes management. These properties benefit in managing diabetes-related outcomes and overall quality of life.

Clinical trial registry of India under registration no

CTRI/2021/04/032956 on 20/04/2021.

Refeeding Syndrome in Pediatric Age, An Unknown Disease: A Narrative Review

Refeeding syndrome (RS) is characterized by electrolyte imbalances that can occur in malnourished and abruptly refed patients. Typical features of RS are hypophosphatemia, hypokalemia, hypomagnesemia, and thiamine deficiency. It is a potentially life-threatening condition that can affect both adults and children, although there is scarce evidence in the pediatric literature. The sudden increase in food intake causes a shift in the body's metabolism and electrolyte balance, leading to symptoms such as weakness, seizures, and even heart failure. A proper management with progressive increase in nutrients is essential to prevent the onset of this condition and ensure the best possible outcomes. Moreover, an estimated incidence of up to 7.4% has been observed in pediatric intensive care unit patients receiving nutritional support, alone or as an adjunct. To prevent RS, it is important to carefully monitor feeding resumption, particularly in severely malnourished individuals. A proper strategy should start with small amounts of low-calorie fluids and gradually increasing the calorie content and amount of food over several days. Close monitoring of electrolyte levels is critical and prophylactic use of dietary supplements such as thiamine may be required to correct any imbalances that may occur. In this narrative review, we aim to provide a comprehensive understanding of RS in pediatric clinical practice and provide a possible management algorithm.

Nutritional status associates with immunotherapy clinical outcomes in recurrent or metastatic head and neck squamous cell carcinoma patients

BACKGROUND

Beyond programmed death-ligand 1 (PD-L1) assessed by the combined positive score (CPS) and tumor mutational burden (TMB), no other biomarkers are approved for immunotherapy interventions. Here, we investigated whether additional clinical and pathological variables may impact on immunotherapy outcomes in recurrent or metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) patients.

METHODS

R/M HNSCC patients treated with immunotherapy were reviewed. Analyzed variables at baseline included: clinicopathological, laboratory, and variables reflecting the host nutritional status such as the prognostic nutritional index (PNI) and albumin. The primary endpoint was progression free survival (PFS). The secondary endpoints were overall survival (OS) and objective response rate (ORR). Univariable and multivariable Cox models were fitted and random forest algorithm was used to estimate the importance of each prognostic variable.

RESULTS

A total of 100 patients were treated with immunotherapy; 50% with single agent and 50% with experimental immunotherapy combinations. In the multivariable analysis, both ECOG performance status (HR: 1.73; 95%CI 1.07-2.82; p = 0.03) and PNI levels (10-point increments, HR: 0.66; 0.46-0.95; p = 0.03) were significantly associated with PFS. However, the derived neutrophil to lymphocyte ratio (dNLR) and lactate dehydrogenase (LDH) were not significantly associated with PFS (p-values > 0.15). In the OS analysis, albumin and PNI were the only statistically significant factors in the multivariable model (p < 0.001).

CONCLUSIONS

In our cohort, PNI and ECOG performance status were most strongly associated with PFS in R/M HNSCC patients treated with immunotherapy. These results suggest that parameters informative of nutritional status should be considered before immunotherapy.

Refeeding syndrome in haemodialysis patients

Nutritional therapies have shown to be efficacious and efficient, despite the overall low level of evidence. It however hides the risk of refeeding syndrome in catabolic malnourished patients. Refeeding syndrome is the metabolic response due to the switch from a starvation to a fed state in the initial phase of nutritional therapy in patients who were severely malnourished or metabolically stressed due to severe illness. Here we describe two cases of chronic kidney disease patients on maintenance haemodialysis, who developed refeeding syndrome. Both the patients had tuberculosis and were severely malnourished with subjective global Assessment (SGA) of grade C. Timely diagnosis and proper management leads to good outcome.

Nutrients and Dietary Approaches in Patients with Type 2 Diabetes Mellitus and Cardiovascular Disease: A Narrative Review

Cardiovascular disease (CVD) is the most common cause of morbidity and mortality in developed countries. The prevalence of CVD is much higher in patients with type 2 diabetes mellitus (T2DM), who may benefit from lifestyle changes, which include adapted diets. In this review, we provide the role of different groups of nutrients in patients with T2DM and CVD, as well as dietary approaches that have been associated with better and worse outcomes in those patients. Many different diets and supplements have proved to be beneficial in T2DM and CVD, but further studies, guidelines, and dietary recommendations are particularly required for patients with both diseases.

Metabolic Consequences of Solid Organ Transplantation

Metabolic complications affect over 50% of solid organ transplant recipients. These include posttransplant diabetes, nonalcoholic fatty liver disease, dyslipidemia, and obesity. Preexisting metabolic disease is further exacerbated with immunosuppression and posttransplant weight gain. Patients transition from a state of cachexia induced by end-organ disease to a pro-anabolic state after transplant due to weight gain, sedentary lifestyle, and suboptimal dietary habits in the setting of immunosuppression. Specific immunosuppressants have different metabolic effects, although all the foundation/maintenance immunosuppressants (calcineurin inhibitors, mTOR inhibitors) increase the risk of metabolic disease. In this comprehensive review, we summarize the emerging knowledge of the molecular pathogenesis of these different metabolic complications, and the potential genetic contribution (recipient +/- donor) to these conditions. These metabolic complications impact both graft and patient survival, particularly increasing the risk of cardiovascular and cancer-associated mortality. The current evidence for prevention and therapeutic management of posttransplant metabolic conditions is provided while highlighting gaps for future avenues in translational research.

Hypophosphatemia and refeeding syndrome in the resumption of nutrition in critical care patients (review)

Refeeding syndrome is a life-threatening condition that occurs when nutrition is restarted in patients with initial malnutrition. For the first time refeeding syndrome was described more than 70 years ago but it still has not been studied enough. The pathophysiology of refeeding syndrome is based on severe electrolyte and metabolic disorders caused by the restoration of nutrition with an initial deficiency of phosphorus, potassium, magnesium which lead to organ failure. Hypophosphatemia is the main feature of the refeeding syndrome while in ICU patients there are many other causes of hypophosphatemia which complicates diagnostics. Most studies on refeeding syndrome have been conducted among patients with anorexia nervosa. In ICU refeeding hypophosphatemia occurs in about 34 % of cases but until recently all guidelines for the management of this condition have been extrapolated from the practice of treatment anorexia nervosa and were based on expert opinion. Several major studies have proven the effectiveness of a hypocaloric feeding during refeeding syndrome in critically ill patients recently. This review is devoted to the problem of refeeding syndrome in patients with anorexia nervosa and critical care patients, differential diagnostics and treatment approaches for this condition.

Concomitant lysine and phosphorus addition to a wheat gluten protein diet highly amplified growth measures of rats

OBJECTIVE

In humans, the effects of lysine-fortified wheat on growth measures was much lower than that of animal experimentations that used phosphorus-containing mineral mix. It is known that wheat contains a limited amount of available phosphorus, which is believed to support growth. The aim of this study was to determine the involvement of phosphorus in growth measures of rats maintained on a lysine-supplemented wheat gluten diet.

METHODS

Forty male Sprague-Dawley (6 wk old) rats were randomly divided into four equal groups and fed wheat gluten protein (10%)-based diets with added lysine (0.6%), phosphorus (0.3%), or both (0.6% lysine and 0.3% phosphorus), ad libitum for 9 wk. Rats were monitored for changes in food intake, body weight, body and liver compositions, plasma urea nitrogen, and albumin.

RESULTS

The addition of lysine or phosphorus to wheat gluten-based diets increased energy intake modestly (∼15%), whereas their combination caused a higher increase (∼45%). Similarly, the magnitude of improvement in weight gain and energy efficiency by the addition of lysine or phosphorus (∼1g/d and 2.7g/MJ, respectively) was much lower than that of the combination (∼4g/d and 8.7g/MJ). In the phosphorus-containing groups, plasma urea nitrogen was significantly reduced and this was associated with higher body protein (%) and hepatic fat (%); whereas plasma albumin was significantly increased in the lysine-containing groups.

CONCLUSION

When using gluten protein, concomitant lysine and phosphorus availability is required to support growth measures, although phosphorus seems to have an independent effect on protein metabolism. Thus, human interventions should consider the improvement of the amino acid profile and phosphorus availability.

Is refeeding syndrome relevant for critically ill patients?

PURPOSE OF REVIEW

To summarize recent relevant studies regarding refeeding syndrome (RFS) in critically ill patients and provide recommendations for clinical practice.

RECENT FINDINGS

Recent knowledge regarding epidemiology of refeeding syndrome among critically ill patients, how to identify ICU patients at risk, and strategies to reduce the potential negative impact on outcome are discussed.

SUMMARY

RFS is a potentially fatal acute metabolic derangement that ultimately can result in marked morbidity and even mortality. These metabolic derangements in ICU patients differ from otherwise healthy patients with RFS, as there is lack of anabolism. This is because of external stressors inducing a hypercatabolic response among other reasons also reflected by persistent high glucagon despite initiation of feeding. Lack of a proper uniform definition complicates diagnosis and research of RFS. However, refeeding hypophosphatemia is commonly encountered during critical illness. The correlations between risk factors proposed by international guidelines and the occurrence of RFS in ICU patients remains unclear. Therefore, regular phosphate monitoring is recommended. Based on recent trials among critically ill patients, only treatment with supplementation of electrolytes and vitamins seems not sufficient. In addition, caloric restriction for several days and gradual increase of caloric intake over days is recommendable.

The relative importance of kinetic mechanisms and variable enzyme abundances for the regulation of hepatic glucose metabolism--insights from mathematical modeling

Background

Adaptation of the cellular metabolism to varying external conditions is brought about by regulated changes in the activity of enzymes and transporters. Hormone-dependent reversible enzyme phosphorylation and concentration changes of reactants and allosteric effectors are the major types of rapid kinetic enzyme regulation, whereas on longer time scales changes in protein abundance may also become operative. Here, we used a comprehensive mathematical model of the hepatic glucose metabolism of rat hepatocytes to decipher the relative importance of different regulatory modes and their mutual interdependencies in the hepatic control of plasma glucose homeostasis.

Results

Model simulations reveal significant differences in the capability of liver metabolism to counteract variations of plasma glucose in different physiological settings (starvation, ad libitum nutrient supply, diabetes). Changes in enzyme abundances adjust the metabolic output to the anticipated physiological demand but may turn into a regulatory disadvantage if sudden unexpected changes of the external conditions occur. Allosteric and hormonal control of enzyme activities allow the liver to assume a broad range of metabolic states and may even fully reverse flux changes resulting from changes of enzyme abundances alone. Metabolic control analysis reveals that control of the hepatic glucose metabolism is mainly exerted by enzymes alone, which are differently controlled by alterations in enzyme abundance, reversible phosphorylation, and allosteric effects.

Conclusion

In hepatic glucose metabolism, regulation of enzyme activities by changes of reactants, allosteric effects, and reversible phosphorylation is equally important as changes in protein abundance of key regulatory enzymes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12915-016-0237-6) contains supplementary material, which is available to authorized users.

Effect of phosphorus supplementation on weight gain and waist circumference of overweight/obese adults: a randomized clinical trial

Background:

Phosphorus status is inversely correlated with body weight; however, the effect of phosphorus supplementation on body weight in a controlled design has not been studied.

Methods:

This is a double-blind, randomized, placebo-controlled trial of 63 adults aged 18–45 years with a body mass index (BMI) of ⩾25 kg m⁻² and normal kidney function at the American University of Beirut. Participants were randomly assigned to the placebo or phosphorus group where daily placebo or phosphorus supplements were ingested with three main meals (breakfast, lunch and dinner) for a period of 12 weeks. Primary outcomes were changes in anthropometric measures, blood metabolites (including lipid profile, glucose and insulin) and subjective appetite scores. The trial is registered with Clinical Trial.gov, NCT02329990.

Results:

Body weight was significantly lower in the phosphorus group when compared with the placebo group (−0.65 kg (95% confidence interval (CI) −1.69 to 0.40) vs 1.13 kg (95% CI 0.19 to 2.06), P=0.01). Similarly, BMI and waist circumference were significantly lower in the phosphorus group when compared with the placebo group (−0.24 kg m⁻² (95% CI −0.59 to 0.12) vs 0.42 kg m⁻² (95% CI 0.05 to 0.78), P=0.01; −3.62 cm (95% CI−4.90 to −2.33) vs 0.38 cm ( 95% CI−0.44 to 1.20), P<0.001; respectively). Several parameters of subjective appetite scores were decreased in the phosphorus-supplemented group.

Conclusions:

Phosphorus supplementation for 12 weeks significantly decreases body weight, BMI, waist circumference and subjective appetite scores. These findings support a promising role of the mineral phosphorus in the prevention and management of obesity, especially abdominal adiposity. The exact mechanisms of action and longer-term effects still need to be elucidated.

Phosphorus ingestion improves oral glucose tolerance of healthy male subjects: a crossover experiment

Background

Fasting serum phosphorus (P) was reported to be inversely related to serum glucose and insulin, while the impact of P ingestion is not well documented. The effect of P intake with or before glucose ingestion on postprandial glucose and insulin statuses was investigated.

Method

Two cross over experiments using healthy male subjects were conducted. Experiment 1: Overnight fasted subjects (n = 7) randomly received: 500 mg of P tablets, glucose (75 g) solution with placebo or 500 mg of P tablets. Experiment 2: Overnight fasted subjects (n = 8) underwent similar procedures to those of experiment 1, except that placebo or 500 mg P tablets were given 60 min prior to glucose ingestion.

Results

In both experiments, serum P decreased following glucose ingestion. Co-ingestion of P with glucose improved, at time 60 min, postprandial glucose (P < 0.05), insulin (P < 0.05), and insulin sensitivity index (p < 0.006), while P pre-ingestion failed to exert similar effect.

Conclusion

This study suggests that postprandial glucose and insulin are affected by exogenous P supply, especially when co-ingested with glucose.