Refeeding syndrome

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Refeeding syndrome
Specialty Gastroenterology
Risk factors

Refeeding syndrome (RFS) is a metabolic disturbance which occurs as a result of reinstitution of nutrition in people who are starved, severely malnourished, or metabolically stressed because of severe illness. When too much food or liquid nutrition supplement is eaten during the initial four to seven days following a malnutrition event, the production of glycogen, fat and protein in cells may cause low serum concentrations of potassium, magnesium and phosphate. [2] [3] The electrolyte imbalance may cause neurologic, pulmonary, cardiac, neuromuscular, and hematologic symptoms—many of which, if severe enough, may result in death.

Contents

Cause

Any individual who has had a negligible nutrient intake for many consecutive days and/or is metabolically stressed from a critical illness or major surgery is at risk of refeeding syndrome. Refeeding syndrome usually occurs within four days of starting to re-feed. Patients can develop fluid and electrolyte imbalance, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications.[ citation needed ]

During fasting, the body switches its main fuel source from carbohydrates to fat tissue fatty acids and it is contended that amino acids from protein sources such muscle as the main energy sources. This timing of protein use is contested: that at first the body practices autophagy to source amino acids rather than being simultaneously used with fat. That the body only uses protein as fuel source when all fat has been depleted. The spleen decreases its rate of red blood cell breakdown thus conserving red blood cells. Many intracellular minerals become severely depleted during this period, although serum levels remain normal. Importantly, insulin secretion is suppressed in this fasting state, and glucagon secretion is increased. [2]

During refeeding, insulin secretion resumes in response to increased blood sugar, resulting in increased glycogen, fat, and protein synthesis. Refeeding increases the basal metabolic rate. The process requires phosphates, magnesium and potassium which are already depleted, and the stores rapidly become used up. Formation of phosphorylated carbohydrate compounds in the liver and skeletal muscle depletes intracellular ATP and 2,3-diphosphoglycerate in red blood cells, leading to cellular dysfunction and inadequate oxygen delivery to the body's organs. Intracellular movement of electrolytes occurs along with a fall in the serum electrolytes, including phosphate and magnesium. Levels of serum glucose may rise, and B1 vitamin (thiamine) may fall. Abnormal heart rhythms are the most common cause of death from refeeding syndrome, with other significant risks including confusion, coma and convulsions and cardiac failure.[ citation needed ]

Anorectics

An anorectic or anorexic is a drug which reduces appetite, resulting in lower food consumption, leading to weight loss. [4]

Examples of anorectics includes stimulants like amphetamines, methylphenidate, and cocaine, along with opiates. Abusing them can lead to prolonged periods of inadequate calorie intake, mimicking anorexia nervosa. If someone misuses these substances and then starts eating normally again, they may be at increased risk of refeeding syndrome.

Clinical situations

The syndrome can occur at the beginning of treatment for eating disorders when patients have an increase in calorie intake and can be fatal. It can also occur when someone does not eat for several days at a time usually beginning after 4–5 days with no food. [5] It can also occur after the onset of a severe illness or major surgery. The shifting of electrolytes and fluid balance increases cardiac workload and heart rate. This can lead to acute heart failure. Oxygen consumption is increased which strains the respiratory system and can make weaning from ventilation more difficult.[ citation needed ]

Signs and Symptoms

The signs and symptoms of refeeding syndrome can vary based on the severity of electrolyte disturbances, including weakness, arrhythmias, and respiratory difficulty. Hypophosphatemia, a key feature of refeeding syndrome, may lead to muscle weakness, heart failure, and impaired diaphragmatic function, while hypokalemia and hypomagnesemia can result in cardiac arrhythmias, seizures, and other severe complications. [6]

Diagnosis

Refeeding syndrome can be fatal if not recognized and treated properly. The electrolyte disturbances of the refeeding syndrome can occur within the first few days of refeeding. Close monitoring of blood biochemistry is therefore necessary in the early refeeding period.[ citation needed ]

The National Institute for Health and Clinical Excellence identifies the following criteria for individuals at high risk for refeeding syndrome: [7]

Either the patient has one or more of the following:

Or the patient has two or more of the following:

Treatment

In critically ill patients admitted to an intensive care unit, if phosphate drops to below 0.65 mmol/L (2.0 mg/dL) from a previously normal level within three days of starting enteral or parenteral nutrition, caloric intake should be reduced to 480 kcals per day for at least two days while electrolytes are replaced. [3] Daily doses of NADH/CoQ10/Thiamine, Vitamin B complex (strong) and a multivitamin and mineral preparation are strongly recommended. Blood biochemistry should be monitored regularly until it is stable. Although clinical trials are lacking in patients other than those admitted to intensive care, it is commonly recommended that energy intake should remain lower than that normally required for the first 3–5 days of treatment of refeeding syndrome for all patients. [1] : 1.4.8 

History

In his 5th century BC work "On Fleshes" (De Carnibus), Hippocrates writes, "if a person goes seven days without eating or drinking anything, in this period most die; but there are some who survive that time but still die, and others are persuaded not to starve themselves to death but to eat and drink: however, the cavity no longer admits anything because the jejunum (nêstis) has grown together in that many days, and these people too die." Although Hippocrates misidentifies the cause of death, this passage likely represents an early description of refeeding syndrome. [8] The Roman historian Flavius Josephus writing in the 1st century AD described classic symptoms of the syndrome among survivors of the siege of Jerusalem. He described the death of those who overindulged in food after the famine, whereas those who ate at a more restrained pace survived. [9] The Shincho Koki chronicle also describes a similar outcome when starved soldiers were fed after the surrender at the siege of Tottori castle on October 25, 1581. [10]

There were numerous cases of refeeding syndrome in the Siege of Leningrad during World War II, with Soviet civilians trapped in the city having become malnourished due to the German blockade. [11]

A common error, repeated in multiple papers, is that "The syndrome was first described after World War II in Americans who, held by the Japanese as prisoners of war, had become malnourished during captivity and who were then released to the care of United States personnel in the Philippines." [12] However, closer inspection of the 1951 paper by Schnitker reveals the prisoners under study were not American POWs but Japanese soldiers who, already malnourished, surrendered in the Philippines during 1945, after the war was over.[ citation needed ]

Refeeding syndrome has also been documented among survivors of the Ebensee concentration camp upon their liberation by the United States Army in May 1945. After liberation, the inmates were fed rich soup; the stomachs of a few presumably could not handle the sudden caloric intake and digestion, and they died. [13] [14]

It is difficult to ascertain when the syndrome was first discovered and named, but it is likely the associated electrolyte disturbances were identified perhaps in Holland, the Netherlands during the so-called Hunger Winter, spanning the closing months of World War II. [15]

See also

Related Research Articles

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<span class="mw-page-title-main">Kwashiorkor</span> Severe protein malnutrition

Kwashiorkor is a form of severe protein malnutrition characterized by edema and an enlarged liver with fatty infiltrates. It is thought to be caused by sufficient calorie intake, but with insufficient protein consumption, which distinguishes it from marasmus. Recent studies have found that a lack of antioxidant micronutrients such as β-carotene, lycopene, other carotenoids, and vitamin C as well as the presence of aflatoxins may play a role in the development of the disease. However, the exact cause of kwashiorkor is still unknown. Inadequate food supply is correlated with occurrences of kwashiorkor; occurrences in high income countries are rare. It occurs amongst weaning children to ages of about five years old.

<span class="mw-page-title-main">Anorexia (symptom)</span> Loss of appetite

Anorexia is a medical term for a loss of appetite. While the term outside of the scientific literature is often used interchangeably with anorexia nervosa, many possible causes exist for a loss of appetite, some of which may be harmless, while others indicate a serious clinical condition or pose a significant risk.

<span class="mw-page-title-main">Fasting</span> Willing abstinence from, or reduced consumption of, food and/or drink

Fasting is the act of refraining from eating, and sometimes drinking. However, from a purely physiological context, "fasting" may refer to the metabolic status of a person who has not eaten overnight, or to the metabolic state achieved after complete digestion and absorption of a meal. Metabolic changes in the fasting state begin after absorption of a meal.

<span class="mw-page-title-main">Starvation</span> Caloric intake below what is needed to maintain an organisms life

Starvation is a severe deficiency in caloric energy intake, below the level needed to maintain an organism's life. It is the most extreme form of malnutrition. In humans, prolonged starvation can cause permanent organ damage and eventually, death. The term inanition refers to the symptoms and effects of starvation. Starvation by outside forces is a crime according to international criminal law and may also be used as a means of torture or execution.

<span class="mw-page-title-main">Parenteral nutrition</span> Intravenous feeding

Parenteral nutrition (PN), or intravenous feeding, is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. The products are made by pharmaceutical compounding entities or standard pharmaceutical companies. The person receives a nutritional mix according to a formula including glucose, salts, amino acids, lipids and vitamins and dietary minerals. It is called total parenteral nutrition (TPN) or total nutrient admixture (TNA) when no significant nutrition is obtained by other routes, and partial parenteral nutrition (PPN) when nutrition is also partially enteric. It is called peripheral parenteral nutrition (PPN) when administered through vein access in a limb rather than through a central vein as in central venous nutrition (CVN).

<span class="mw-page-title-main">Hypocalcemia</span> Low calcium levels in ones blood serum

Hypocalcemia is a medical condition characterized by low calcium levels in the blood serum. The normal range of blood calcium is typically between 2.1–2.6 mmol/L, while levels less than 2.1 mmol/L are defined as hypocalcemic. Mildly low levels that develop slowly often have no symptoms. Otherwise symptoms may include numbness, muscle spasms, seizures, confusion, or in extreme cases cardiac arrest.

<span class="mw-page-title-main">Marasmus</span> Medical condition

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Hypermagnesemia is an electrolyte disorder in which there is a high level of magnesium in the blood. Symptoms include weakness, confusion, decreased breathing rate, and decreased reflexes. Hypermagnesemia can greatly increase the chances of adverse cardiovascular events. Complications may include low blood pressure and cardiac arrest.

<span class="mw-page-title-main">Hypophosphatemia</span> Lack of phosphate in the blood

Hypophosphatemia is an electrolyte disorder in which there is a low level of phosphate in the blood. Symptoms may include weakness, trouble breathing, and loss of appetite. Complications may include seizures, coma, rhabdomyolysis, or softening of the bones.

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References

  1. 1 2 "Evidence — Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition — Guidance". National Institute for Health and Care Excellence (NICE). 22 February 2006 [Updated 4 August 2017]. Web page with link to full guideline CG32.
  2. 1 2 Mehanna HM, Moledina J, Travis J (June 2008). "Refeeding syndrome: what it is, and how to prevent and treat it". BMJ. 336 (7659): 1495–8. doi:10.1136/bmj.a301. PMC   2440847 . PMID   18583681.
  3. 1 2 Doig, GS; Simpson, F; Heighes; Bellomo, R; Chesher, D; Caterson, ID; Reade, MC; Harrigan, PWJ (2015-12-01). "Restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial". The Lancet Respiratory Medicine. 3 (12): 943–952. doi:10.1016/S2213-2600(15)00418-X. ISSN   2213-2619. PMID   26597128.
  4. ↑ Lemke, Thomas L.; Williams, David A., eds. (2012). "Anorexiants as Pharmacologic Agents in the Management of Obesity". Foye's Medicinal Chemistry. Lippincott Williams & Wilkins. pp. 1451–6. ISBN   978-1-60913-345-0.
  5. ↑ Webb GJ, Smith K, Thursby-Pelham F, Smith T, Stroud MA, Da Silva AN (2011). "Complications of emergency refeeding in anorexia nervosa: case series and review". Acute Medicine. 10 (2): 69–76. doi: 10.52964/AMJA.0470 . PMID   22041604.
  6. ↑ Aggarwal, A.; Morgan, P. (September 2018). "An evaluation of pabrinex prescribing for the prevention of refeeding syndrome in adult patients commencing parenteral nutrition at king's college hospital". Clinical Nutrition. 37: S102. doi:10.1016/j.clnu.2018.06.1393. ISSN   0261-5614.
  7. 1 2 3 Butt, Ifrah; Ulloa, Nicolas; Surapaneni, Balarama K.; Kasmin, Franklin; Butt, Ifrah; Ulloa, Nicolas; Surapaneni, Balarama K.; Kasmin, Franklin (17 July 2019). "Refeeding Syndrome and Non-Alcoholic Wernicke's Encephalopathy in a Middle-aged Male Initially Presenting with Gallstone Pancreatitis: A Clinical Challenge". Cureus. 11 (7): e5156. doi: 10.7759/cureus.5156 . ISSN   2168-8184. PMC   6750637 . PMID   31538039. Creative Commons by small.svg  This article incorporates textfrom this source, which is available under the CC BY 3.0 license.
  8. ↑ Hippocrates of Kos. De Carnibus. 5th century BCE.
  9. ↑ The Wars of the Jews by Flavius Josephus. October 2001. p. book V, chapter XIII, paragraph 4. Retrieved 2018-05-22– via www.gutenberg.org.
  10. ↑ "Researchers play detective to track earliest case of medical malady | The Asahi Shimbun: Breaking News, Japan News and Analysis". The Asahi Shimbun. Retrieved 2024-01-31.
  11. ↑ Juliana Machado; et al. (March 5, 2009). "Refeeding syndrome, an undiagnosed and forgotten potentially fatal condition". BMJ Case Reports. 2009: bcr07.2008.0521. doi:10.1136/bcr.07.2008.0521. PMC   3028379 . PMID   21686764.
  12. ↑ Schnitker MA, Mattman PE, Bliss TL (1951). "A clinical study of malnutrition in Japanese prisoners of war". Annals of Internal Medicine. 35 (1): 69–96. doi:10.7326/0003-4819-35-1-69. PMID   14847450.
  13. ↑ Persinger, Robert B. "Remembering Ebensee 1945 Robert B. Persinger, May 6th 2005". Memorial Ebensee. Archived from the original on 7 October 2011.
  14. ↑ Nawyn, Kathleen J. "The Liberation of the Ebensee Concentration Camp, May 1945". history.army.mil. U.S. Army Center of Military History. Retrieved 1 October 2018.
  15. ↑ Burger, GCE; BSandstead, HR; Drummond, J (1945). "Starvation in Western Holland: 1945". The Lancet. 246 (6366): 282–83. doi:10.1016/s0140-6736(45)90738-0.

Bibliography

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