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Occurrence of refeeding syndrome in adults started on artificial nutrition support: prospective cohort study
  1. Alan Rio1,
  2. Kevin Whelan2,
  3. Louise Goff2,
  4. Dianne Patricia Reidlinger2,
  5. Nigel Smeeton3
  1. 1Department of Nutrition and Dietetics, King's College Hospital, London, UK
  2. 2Diabetes and Nutritional Sciences Division, King's College London, School of Medicine, London, UK
  3. 3Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
  1. Correspondence to Mr Alan Rio; Alan.Rio.1{at}


Background Refeeding syndrome is a potentially life-threatening condition characterised by severe intracellular electrolyte shifts, acute circulatory fluid overload and organ failure. The initial symptoms are non-specific but early clinical features are severely low-serum electrolyte concentrations of potassium, phosphate or magnesium. Risk factors for the syndrome include starvation, chronic alcoholism, anorexia nervosa and surgical interventions that require lengthy periods of fasting. The causes of the refeeding syndrome are excess or unbalanced enteral, parenteral or oral nutritional intake. Prevention of the syndrome includes identification of individuals at risk, controlled hypocaloric nutritional intake and supplementary electrolyte replacement.

Objective To determine the occurrence of refeeding syndrome in adults commenced on artificial nutrition support.

Design Prospective cohort study.

Setting Large, single site university teaching hospital. Recruitment period 2007–2009.

Participants 243 adults started on artificial nutrition support for the first time during that admission recruited from wards and intensive care.

Main outcome measures Primary outcome: occurrence of the refeeding syndrome. Secondary outcome: analysis of the risk factors which predict the refeeding syndrome. Tertiary outcome: mortality due to refeeding syndrome and all-cause mortality.

Results 133 participants had one or more of the following risk factors: body mass index <16–18.5≥(kg/m2), unintentional weight loss >15% in the preceding 3–6 months, very little or no nutritional intake >10 days, history of alcohol or drug abuse and low baseline levels of serum potassium, phosphate or magnesium prior to recruitment. Poor nutritional intake for more than 10 days, weight loss >15% prior to recruitment and low-serum magnesium level at baseline predicted the refeeding syndrome with a sensitivity of 66.7%: specificity was >80% apart from weight loss of >15% which was 59.1%. Baseline low-serum magnesium was an independent predictor of the refeeding syndrome (p=0.021). Three participants (2% 3/243) developed severe electrolyte shifts, acute circulatory fluid overload and disturbance to organ function following artificial nutrition support and were diagnosed with refeeding syndrome. There were no deaths attributable to the refeeding syndrome, but (5.3% 13/243) participants died during the feeding period and (28% 68/243) died during hospital admission. Death of these participants was due to cerebrovascular accident, traumatic injury, respiratory failure, organ failure or end-of-life causes.

Conclusions Refeeding syndrome was a rare, survivable phenomenon that occurred during hypocaloric nutrition support in participants identified at risk. Independent predictors for refeeding syndrome were starvation and baseline low-serum magnesium concentration. Intravenous carbohydrate infusion prior to artificial nutrition support may have precipitated the onset of the syndrome.

  • Nutrition & Dietetics

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