Refeeding Syndrom: Ein Update. Prof. Philipp Schuetz, Leitender Arzt Medizinische Uniklinik, Kantonsspital Aarau GESKES Kurs Aarau, April 14 th 2016

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1 Refeeding Syndrom: Ein Update Prof. Philipp Schuetz, Leitender Arzt Medizinische Uniklinik, Kantonsspital Aarau GESKES Kurs Aarau, April 14 th Historical perspective First observed in survivors of the Conzentration Camps 1

unbalanced refeeding of a malnourished catabolic patient NICE. Clin. Guidelines 2006 / Stanga Z. Eur J Clin Nutr 2008 Prevalence of refeeding syndrome 10% pat.

2 Is there a Definition of the refeeding syndrome? Life-threatening condition characterised by low-serum electrolyte and vitamin concentrations fluid imbalance sodium-retention disturbance of organ function resulting from over-rapid or unbalanced refeeding of a malnourished catabolic patient NICE. Clin. Guidelines 2006 / Stanga Z. Eur J Clin Nutr 2008 Prevalence of refeeding syndrome 10% pat. with gastrointestinal fistulae Fan et al. Nutrition % elderly patients (age 65 y) Kagansky et al. J Intern Med % cancer patients Gonzalez et al. Nutr Hosp % malnourished patients Hernandez-Aranda et al. Rev Gastroenterol Mex % pat. affected by anorexia nervosa (n = 69, mean BMI 15 kg/m²) Ornstein. J Adolesc Health

% Patients 14.04.2016 Prevalence of refeeding syndrome 10% pat. with gastrointestinal fistulae Fan et al. Nutrition 2004 14% elderly patients (age 65 y) Kagansky et al.

3 % Patients Prevalence of refeeding syndrome 10% pat. with gastrointestinal fistulae Fan et al. Nutrition % elderly patients (age 65 y) Kagansky et al. J Intern Med % cancer patients Gonzalez et al. Nutr Hosp % malnourished patients Hernandez-Aranda et al. Rev Gastroenterol Mex % pat. affected by anorexia nervosa (n = 69, mean BMI 15 kg/m²) Ornstein. J Adolesc Health 2003 HYPOPHOSPHATAEMIA (nadir) 55% 98% Days after start refeeding Pathophysiologic aspects of the RFS Starvation or malnutrition catabolic state insulin glucagon Boateng AA et al. Nutrition

4 Pathophysiologic aspects of the RFS Starvation or malnutrition catabolic state insulin glucagon Gluconeogenesis, proteolysis loss of weight depletion of vitamin & mineral stores Boateng AA et al. Nutrition 2010 Pathophysiologic aspects of the RFS Starvation or malnutrition catabolic state Gluconeogenesis, proteolysis REFEEDING Glucose insulin glucagon loss of weight depletion of vitamin & mineral stores lipogenesis steatohepatitis thiamine Wernicke enc., met. acidosis hyperosmotic state neutrophil function Boateng AA et al. Nutrition

5 Pathophysiologic aspects of the RFS Starvation or malnutrition catabolic state Gluconeogenesis, proteolysis REFEEDING Glucose insulin glucagon loss of weight depletion of vitamin & mineral stores lipogenesis steatohepatitis thiamine Wernicke enc., met. acidosis hyperosmotic state neutrophil function Insulin Na ECV heart failure edema Boateng AA et al. Nutrition 2010 Pathophysiologic aspects of the RFS Starvation or malnutrition catabolic state Gluconeogenesis, proteolysis REFEEDING Glucose insulin glucagon loss of weight depletion of vitamin & mineral stores lipogenesis steatohepatitis thiamine Wernicke enc., met. acidosis hyperosmotic state neutrophil function Insulin Na ECV heart failure edema Transcellular shifts of Glucose, PO 4, K, Mg Mg, K, PO 4 spasms tetany arrhythmias Boateng AA et al. Nutrition

6 Pathophysiologic aspects of the RFS PO 4 ATP RBC ATP, 2.3-DPG hemolysis anemia O 2 -delivery ischemia, hyperventilation central nervous, gastrontestinal system system respiratory alkalosis weakness tremor ataxia paralysis delirium, coma loss of appetite constipation Boateng AA et al. Nutrition 2010 Pathophysiologic aspects of the RFS PO 4 ATP RBC ATP, 2.3-DPG muscle weakness myalgia dyspnea rhabdomyolysis acute tubular necrosis hemolysis anemia O 2 -delivery ischemia, hyperventilation central nervous, gastrontestinal system system weakness tremor ataxia paralysis delirium, coma loss of appetite constipation respiratory alkalosis Boateng AA et al. Nutrition

necrosis anemia hemolysis O 2 -delivery ischemia, hyperventilation

paralysis delirium, coma anorexia constipation respiratory alkalosis

Nutrition 2010 Criteria for determination of patients at risk of RFS ONE

preceding 3-6 months Very little or no nutritional intake for > 10 days

7 Pathophysiologic aspects of the RFS PO 4 ATP RBC ATP, 2.3-DPG muscle weakness myalgia dyspnea rhabdomyolysis acute tubular necrosis anemia hemolysis O 2 -delivery ischemia, hyperventilation central nervous, gastrontestinal system system weakness tremor ataxia paralysis delirium, coma anorexia constipation respiratory alkalosis Boateng AA et al. Nutrition 2010 Criteria for determination of patients at risk of RFS ONE OF THE FOLLOWING BMI < 16 kg/m2 Unintentional weight loss > 15% in the preceding 3-6 months Very little or no nutritional intake for > 10 days Low levels of serum magnesium, phosphate or potassium prior to feed TWO OF THE FOLLOWING BMI < 18.5 kg/m2 Unintentional weight loss > 10% in the preceding 3-6 months Very little or no nutritional intake for > 5 days History of alcool or drug abuse NICE. Clinical Guidelines 2006 / Stanga Z et al. EJCN

Criteria for determination of patients at risk of RFS ONE OF THE FOLLOWING BMI <

or no nutritional intake for > 10 days Low levels of serum magnesium, phosphate or

5 kg/m2 Unintentional weight loss > 10% in the preceding 3-6 months Very little or

PATIENTS AT RISK Hungerstrike, anorexia nervosa After bariatric surgery, short

Clinical Guidelines 2006 / Stanga Z et al.

8 Criteria for determination of patients at risk of RFS ONE OF THE FOLLOWING BMI < 16 kg/m2 Unintentional weight loss > 15% in the preceding 3-6 months Very little or no nutritional intake for > 10 days Low levels of serum magnesium, phosphate or potassium prior to feed TWO OF THE FOLLOWING BMI < 18.5 kg/m2 Unintentional weight loss > 10% in the preceding 3-6 months Very little or no nutritional intake for > 5 days History of alcool or drug abuse FURTHER PATIENTS AT RISK Hungerstrike, anorexia nervosa After bariatric surgery, short bowel syndrome Oncology patients and fraily elderly NICE. Clinical Guidelines 2006 / Stanga Z et al. EJCN 2007 Criteria for confirmation RFS Severly low electrolytes PO 4 < 0.32 mmol/l K < 2.5 mmol/l Mg < 0.5 mmol/l Fluid overload Peripheral oedema or acute circulatory fluid overload REFEEDING SYNDROME Disturbance to organ function respiratory failure, cardiac failure or pulmonary oedema Rio A et al. BMJ Open 2013 / Crook MA et al. Nutrition

9 General recommendations for management of RFS NICE. Clinical Guidelines 2006 / Stanga Z et al. EJCN 2007 General recommendations for management of RFS NICE. Clinical Guidelines 2006 / Stanga Z et al. EJCN

10 General recommendations for management of RFS NICE. Clinical Guidelines 2006 / Stanga Z et al. EJCN 2007 General recommendations for management of RFS NICE. Clinical Guidelines 2006 / Stanga Z et al. EJCN

11 General recommendations for management of RFS NICE. Clinical Guidelines 2006 / Stanga Z et al. EJCN 2007 General recommendations for management of RFS MEASURES DAYS 1-3 Energy Electrolytes Fluid Micronutrients Biochemistry Clinical exam kcal/kg/d (50-60% carbohydrates, 30-40% fat and 15-20% protein) Prophylactic supplementation Phosphate mmol/kg/d Potassium mmol/kg/d Magnesium mmol/kg/d ml/kg/d, sodium restriction <1 mmol/kg/d mg thiamine IV or PO before feeding is initiated, afterward daily Vitamines 200% DRI Trace elements 100% DRI PO 4, K, Mg, Glucose, Ca, Na daily BP, P, O-sat., hydration state, cardiopulmonary, weight NICE. Clinical Guidelines 2006 / Stanga Z et al. EJCN

12 General recommendations for management of RFS MEASURES DAYS 4-6 and DAYS 7-10 Energy Electrolytes Fluid Micronutrients Biochemistry Clinical exam kcal/kg/d, from day 7: kcal/kg/d (50-60% carbohydrates, 30-40% fat and 15-20% protein) Suppl. according to plasma concentrations Phosphate <0.6 mmol/l mmol over 12 h Potassium <3.5 mmol/l mmol over 12 h Magnesium <0.5 mmol/l 2-4 g MgSO 4 over 12 h ml/kg/d, from day 7: 30 ml/kg/d Vitamines 200% DRI, Trace elements 100% DRI PO 4, K, Mg, 2x/wk, afterward 1x/wk hydration state, cardiopulmonary, weight NICE. Clinical Guidelines 2006 / Stanga Z et al. EJCN 2007 Reference Energy Protein Electrolytes Fluids Micronutrients Solomon & Kirby JPEN 1990 Dewar & Horvath A Guide to Clinical Nutrition 2001 Crook et al. Nutrition 2001 Kraft et al. Nutr Clin Pract 2005 NICE Guidelines 2006 Stanga et al. Eur J Clin Nutr kcal/kg g _ 20 kcal/kg _ Replenish as required _ Thiamine IV or PO for 2 d 20 kcal/kg g Replenish as required _ Thiamine IV or PO for 2 d 25% of requirements 10 kcal/kg, high risk: 5 kcal/kg 10 kcal/kg 50-60% KH 30-40% fat mmol PO 4 pro 1000 kcal Replenish as required KCl: 2-4 mmol/kg Mg: mmol/kg PO 4 : mmol/kg 10-20% KCl: 1-3 mmol/kg Mg: mmol/kg PO 4 : mmol/kg Na: <1 mmol/kg <1l/d Thiamine mg IV or 100 mg PO 5-7 d & multivitamin 0 fluid balance 20-30ml/kg /d, 0 fluid balance mg Thiamine PO for 10 d & multivitamin mg Thiamine IV or PO for 3 d & multivitamin 12

Reference Energy Protein Electrolytes Fluids Micronutrients Solomon & Kirby JPEN 1990 Dewar & Horvath A Guide to Clinical Nutrition 2001 Crook et al. Nutrition 2001 Kraft et al.

5g _ 20 kcal/kg _ Replenish as required _ Thiamine IV or PO for 2 d 20 kcal/kg 1.2-1.

13 Reference Energy Protein Electrolytes Fluids Micronutrients Solomon & Kirby JPEN 1990 Dewar & Horvath A Guide to Clinical Nutrition 2001 Crook et al. Nutrition 2001 Kraft et al. Nutr Clin Pract 2005 NICE Guidelines 2006 Stanga et al. Eur J Clin Nutr kcal/kg g _ 20 kcal/kg _ Replenish as required _ Thiamine IV or PO for 2 d 20 kcal/kg g Replenish as required _ Thiamine IV or PO for 2 d 25% of requirements 10 kcal/kg, high risk: 5 kcal/kg 10 kcal/kg 50-60% KH 30-40% fat mmol PO 4 pro 1000 kcal Replenish as required KCl: 2-4 mmol/kg Mg: mmol/kg PO 4 : mmol/kg 10-20% KCl: 1-3 mmol/kg Mg: mmol/kg PO 4 : mmol/kg Na: <1 mmol/kg <1l/d Thiamine mg IV or 100 mg PO 5-7 d & multivitamin 0 fluid balance 20-30ml/kg /d, 0 fluid balance mg Thiamine PO for 10 d & multivitamin mg Thiamine IV or PO for 3 d & multivitamin but what is the evidence? 13

When did refeeding syndrome occur? IV. Does refeeding syndrome correlate with adverse outcome? V.

14 Systematic review on RFS (2015, Natalie Friedli) Research Questions: I. What are definitions used for refeeding syndrome? II. How high is the incidence of refeeding syndrome? III. When did refeeding syndrome occur? IV. Does refeeding syndrome correlate with adverse outcome? V. What are risk factors for refeeding syndrome? VI. What are therapeutic strategies to prevent refeeding syndrome? Systematic review on RFS (2015, Natalie Friedli) 14

15 Definitions for RFS Author Y N= Def. RFS M arik, P. E., et al drop of PO4 by > 0.16mmol/l to below 0.65mmol/l Gaudiani L., et al Hypophosphatemia Gaudiani L., et al Hypophosphatemia <2.7mg/dl (0.87mmol/l) Heimburger, D.C., et Hypophosphatemia and clinical symptoms al. Nagata, J.M., et al Phosphorus < 3mg/dl Coskun, R., et al PO4 2.4 mg/l (0.77 mmol/l) Zeki, S., Clukin A., et PO4 < 0.6mmol/l al. Kagansky, N. et al PO4 <0.77mmol/l M arvin, V., et al PO4 drop of 0.15mmol/l to <0.80mmol/l from baseline in the first 7d of PN in patients with a period of > 48h without food. Terlevich, A., et al PO4 of < 0.50 mmol/l Lubart, E., et al PO4<1.6mg/dl (0.51mmol/l) Gonzalez Avila, G., et PO4<2.5 mg/dl (=0.8mmol/l) al. Goyale, A., et al a PO4 drop of >30%during the Refeeding hypophosphatemia = first 36h of PN administration. Whitelaw, M., et al severe electrolyte and fluid shifts in response to refeeding Luque, S., et al severe hydroelectro-lytic and metabolic disturbances Leclerc, A., et al Shift in fluid and electrolytes Garber A.K., et al Shifts in electrolytes Vignaud, M., et al all adverse events occuring during nutritional rehabilitation Hernandez-Aranda, J.C., et al any drop of electrolyte values under the reference range. M anning, S., et al Changes in fluid and electrolyte balance Grasso, S., et al electorlyte disorders Flesher, M.E., et al Electrolyte depletion associated with complications in early enteral feeding Gentile, M.G., et al ) Salt / water retention. 2) HP 3) Depletion of other electrolytes like K and M g and vitamins as B1, B6, etc. 4) Depletion of the thiamine co-factor of glycolysis. (M arinella, et. al / Solomon et al.) Hofer, M., et al Rio A, Whelan K, Goff L, et al K <2.5, PO4 <0.32, M g <0.5 mmol/l 2. Peripheral oedema or acute circulatory fluid overload 3. Disturbance to organ function including espiratory failure, cardiac failure and pulmonary oedema. Saito, S., T. Kobayashi, and S. Kato cardiovascular, repsiratory, neurological or psychological changes with Hypophosphatemia Elnenaei, M.O., et al Clinical features Chen Li-Ju, Chen Huan-Lin, et al Electrolyte shift and clinical symptoms Eichelberger, M., et al imbalances of electrolyte and fluid homeostasis, and organ dysfunction Faintuch, J., et al Relevant Electrolyte disturbances and clinical symptoms Herranz A., et al severe HP, hypok, hypom g, associated edema, and impaired carbohydrate metabolism Fan, C.G., et al symptoms and signs of electrolyte disturbances. - Hypophosphatämie - Elektrolytverschiebungen - Klinische Symptome Incidence rates for RFS Author Y N= Pat. Kollektiv Def. RFS Inzidenz 1. K <2.5, PO4 <0.32, M g <0.5 mmol/l 2. Peripheral oedema or acute circulatory fluid overload 3. Disturbance to organ function including Hofer, M patients under refeeding 0% AN espiratory failure, cardiac failure and pulmonary oedema. 1) Salt / water retention. 2) HP 3) Depletion of other electrolytes like K and M g and vitamins as B1, B6, etc. 4) Depletion of the thiamine co-factor Gentile, M.G Very severe AN in-patients 0% of glycolysis. Adolescents with AN between 12-18yrs, hospitalized fort he first Leclerc, A Shift in fluid and electrolytes 0% time for nutritional rehabilitation Elnenaei, M.O patients referred for commencement of PN Clinical features 0% Faintuch, J hungerstrikers who refuesed food for 43 days Relevant Electrolyte disturbances and clinical symptoms 0% Herranz A In patients receiving PN severe HP, hypok, hypom g, associated edema, and impaired carbohydrate metabolism after the start of NS with PN. 0% Luque, S adult patients with malnutrition receiving PN severe hydroelectro-lytic and metabolic disturbances 0% M anning, S alcoholics hospitalised for withdrawal Changes in fluid and electrolyte balance 0% Heimburger, D.C HIV infected patients Hypophosphatemia and clinical symptoms 0.70% 1. K <2.5, PO4 <0.32, M g <0.5 mmol/l 2. Peripheral oedema or acute circulatory fluid overload 3. Disturbance to organ function including Rio A, Whelan K, Goff Adults started on artificial nutrition support 2% L espiratory failure, cardiac failure and pulmonary oedema. Eichelberger, M Patients on a hungerstrike imbalances of electrolyte and fluid homeostasis, and organ dysfunction 3% Fan, C.G Patients with gastrointestinal fistula symptoms and signs of electrolyte disturbances 9.40% Vignaud, M Patients with AN all adverse events occuring during nutritional rehabilitation 10% Zeki, S., Clukin A Patients receiving PN or EN, not ICU PO4 < 0.6mmol/l 15% Chen Li-Ju, Chen Huan-Lin high risk for RFS according to NICE Electrolyte shift and clinical symptoms 20% people at guidelines. Gonzalez Avila, G Cancer patients receiving EN or PN PO4<2.5 mg/dl (=0.8mmol/l) 24.50% Lubart, E Frail elderly patients with feeding problems >72h PO4<1.6mg/dl (0.51mmol/l) 25% M arik, P. E ICU patients starved for at least 48h drop of PO4 by > 0.16mmol/l to below 0.65mmol/l 34% M arvin, V Adults on PN PO4 drop of 0.15mmol/l to <0.80mmol/l from baseline in the first 7d 34% Gaudiani L Adults with AN Hypophosphatemia 37% Gaudiani L AN patients hospitalized for refeeding Hypophosphatemia <2.7mg/dl (0.87mmol/l) 45% Saito, S Eating disorders patients hospitalized on a psychiatric ward cardiovascular, repsiratory, neurological or psychological changes with HP during RF 45% Coskun, R patients admitted to ICU and receiving either EN or PN PO4 2.4 mg/l (0.77 mmol/l) 52.14% Goyale, A patients referred for PN PO4 drop of >30%during the first 36h of PN administration. 62% Hernandez-Aranda, J.C with EN/PN screened. All with mild and severe malnutrition were included, they received PN or EN support for >7d any drop of electrolyte values under the reference range. 48% Flesher, M.E M alnourished patients on enteral feeding protocol Electrolyte depletion associated with complications in early enteral feeding 80% % falls klinische Symptome nötig % falls Hypophosphatämie Diagnosekriterium - Bis 80% nicht näher definierte Elektrolytverschiebung 15

16 Time course of appearance of RFS Author Y Title N= Def. RFS Occurence of RFS Gaudiani L., et al Severe Anorexia Nervosa: Outcomes from a M edical Stabilization Unit 25 Hypophosphatemia <2.7mg/dl (0.87mmol/l) 3.4 days Raj, K.S., et al Hypomagnesemia in adolescents with eating disorders hospitalized for medical instability 541 metabolic and clinical changes 4.9 +/- 5.5 days Fan, C.G., et al Refeeding Syndrome in Patients With Gastrointestinal Fistula 15 symptoms and signs of electrolyte disturbances. within 24h Gonzalez Avila, G., et al The incidence of the RFS in cancer patients who receive artificial nutritional treatment 106 PO4<2.5 mg/dl (=0.8mmol/l) Within 72h Hernandez-Aranda, J.C., et al M alnutrition and total parenteral nutrition: a cohort study to determine the incidence of refeeding syndrome 50 any drop of electrolyte values under the reference range. 55%at the third day Kagansky, N. et al Hypophosphatemia in old patients is associated with the RFS and reduced survival 651 HP <0.77mmol/l detected on 10.9+/- 21.5days of hospitalisastion Lubart, E., et al M ortality after Nastogastric Tube Feeding initiation in Long-Term Care Elderly with Oropharyngeal Dysphagia - The Contribution of RFS 40 PO4<1.6mg/dl (0.51mmol/l) 2nd and 3rd day M arik, P. E., et al Refeeding hypophosphatemia in Critically Ill Patients in an ICU 62 drop of PO4 by > 0.16mmol/l to below 0.65mmol/l 1.9 +/- 1.1 days M arvin, V., et al Incidence of hypophosphataemia in patients on PN 250 PO4 drop of 0.15mmol/l to <0.80mmol/l from baseline in the first 7d 3 days - Wenige Daten - Im Bereich der ersten 72h - Einzelne auch erst nach >10d. Correlation with adverse outcome? Author Year n= Population Mortality rate Other adverse outcome Vignaud, M., et al Patients with AN admitted to ICU 71% Hernandez-Aranda, J.C., et al Patiens receiving PN/EN and mild or severe malnutrition 29%(p=0.059). Longer LOS Lubart, E., et al Frail elderly patients with feeding problems >72h RFS as the cause of death in 6% Heimburger, D.C., et al HIV infected patients lower survival probability at 12 weeks Kagansky, N. et al Patients having HP compared with patients not having HP threefold increased mortality rates, but not an independent predictor for mortality Longer LOS Rio A, Whelan K, Goff L, et al Adults started on artificial nutrition support 0% Eichelberger, M., et al Patients on a hungerstrike 0% Goyale, A., et al Patients referred for PN when EN was contraindicated No correlation between death and RH Zeki, S., Clukin A., et al Patients receiving PN or EN, not ICU Death within 7 days and RH were not associated Coskun, R., et al Patients admitted to ICU and receiving either PN or EN ICU LOS longer M arik, P. E., et al ICU patients starved for at least 48h Longer LOS - Erhöhte Mortalität in einigen Studien - Keine Korrelation in anderen - Stark abhängig vom Patientenkollektiv - Schlechte Datenlage 16

17 Risk factors for RFS? Risk factor Numbers of studies using this Risk factor NICE 6 Poor caloric intake 6 Weight loss 3 Malnourished patients 3 Nasogastric feeding 3 No risk factors 3 Age >60yrs 2 Low prealbumin levels 2 Nutrition support introduced at full strength 2 Alcohol abuse 1 High NRS 1 Hypoalbuminaemia 1 Low serum magnesium level at baseline 1 IGF-1 <63.7ug/l 1 Cancer patients 1 Patients with GI-fistula 1 NICE criteria for identifying patients at high risk of refeeding problems (level D recommendations*) - Either the patient has one or more of the following: - BMI <16kg/m2 - Unintentional weight loss >15% in the past 3-6m - Little or no nutritional intake for >10 d - Low levels of K, PO4, or Mg before feeding. - Or the patient has two or more of the following: - BMI < Unintentional weight loss >10% in the past 3 6 m - Little or no nutritional intake for >5 d - History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics - NICE Empfehlungen scheinen zutreffend zu sein, ggf. müssen sie ergänzt werden. Therapeutic strategies for RFS Normokalorisch vs hypokalorische Ernährung Prophylaktische Elektrolytsubstitution und Gabe von Thiamin vs. keine Substitution - Pro und Kontra ausgeglichen! 17

18 NEW Randomized Trial in RFS (ICU) 13 hospital ICUs in Australia (11 sites) and New Zealand (two sites). 339 adult critically ill patients who developed refeeding syndrome within 72 h of commencing nutritional support in the ICU were enrolled Definition: serum phosphate concentration decreased to below 0.65 mmol 18

19 19

treatment of malnourished medical in patients

20 Nutritional reguirements / goals Schuetz P, Stanga Z, Keller U, Kondrup J, et al, Consensus guidelines for treatment of malnourished medical in patients (submitted) FelderS, Schuetz P, Schweiz Med Forum 2014;14(24):

21 Nutritional reguirements / goals 21

Hypokalaemia Hypomagnesaemia Hypophosphataemia Thiamine deficiency Salt & water retention Starvation

SYNDROME Depletion of mineral and vitamin stores glucose uptake utilization of thiamine Glucose

Eur J Clin Nutr 2008 Pending questions To date only low quality evidence exists.

so far conflicting statements possible start feeding with 20 kcal/kg/d in hospital?

22 Hypokalaemia Hypomagnesaemia Hypophosphataemia Thiamine deficiency Salt & water retention Starvation or malnutrition Gluconeogenesis, glycogenolysis & protein catabolism K + Mg 2+ PO 4 2- REFEEDING SYNDROME Depletion of mineral and vitamin stores glucose uptake utilization of thiamine Glucose major energy source protein synthesis Na + retention ECV Insulin secretion Stanga Z. Eur J Clin Nutr 2008 Pending questions To date only low quality evidence exists... Too cautious energy step up? so far conflicting statements possible start feeding with 20 kcal/kg/d in hospital? Buildup of full food intake within 3-4 days? reduction of the catabolic phase Do we have to give electrolytes in a prophylactic way? prevention is better than cure Reliable predictors? How important is the clinical examination? 22

MANAGEMENT AND PREVENTION OF REFEEDING SYNDROME IN INPATIENTS: A PRACTICAL APPROACH

MANAGEMENT AND PREVENTION OF REFEEDING SYNDROME IN INPATIENTS: A PRACTICAL APPROACH Prof. Zeno Stanga, MD Nutritional Medicine Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism