ABSTRACT

Objective:

One of the most important issues to be considered in patients who are started on nutritional therapy is refeeding syndrome (RS), which can occur within the first four days. Hypophosphatemia (serum phosphorus level <2.5 mg/dL) is an early symptom of refeeding syndrome. This study aimed to evaluate the rate of hypophosphatemia in different patient groups receiving nutritional therapy. This has been undertaken to examine the one-year follow-up results of an experienced clinical nutrition team (CNT) and the factors that cause hypophosphatemia.

Materials and Methods:

In this retrospective study, patients over 18 years of age and followed up by the CNT between January 2018-January 2019 were included. Patients’ characteristics, nutritional characteristics, serum phosphate levels and the relationship between these parameters and hypophosphatemia were evaluated.

Results:

Out of 622 patients who were included in the study, 11% showed hypophosphatemia. It was determined that 51.3% of the patients with hypophosphatemia were male (n=39), the median age was 66 years (range 21-95). The development of hypophosphatemia was ascertained to have a significant relationship with age (p=0.04), diet (p=0.01), surgery history (p=0.03), the status of reaching the target in parenteral nutrition (p=0.04) and the presence of additional disease (p=0.02). The multivariate regression analysis showed advanced age (p=0.03, Exβ=1.01) and surgery status (p=0.009, Exβ=2) increased the risk of hypophosphatemia.

Conclusion:

The advanced age and surgery, along with other already known factors, seem to increase the risk of hypophosphatemia, and therefore, more attention should be given to the clinical nutrition treatment in these patients.

Keywords: Hypophosphatemia, clinical nutrition team, refeeding syndrome

References

Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr 2017;36:49-64.

SCHNITKER MA, MATTMAN PE, BLISS TL. A clinical study of malnutrition in Japanese prisoners of war. Ann Intern Med 1951;35:69-96.

Hearing SD. Refeeding syndrome. BMJ 2004;328:908-9.

Khan LU, Ahmed J, Khan S, Macfie J. Refeeding syndrome: a literature review. Gastroenterol Res Pract 2011;2011:410971.

Crook MA, Hally V, Panteli JV. The importance of the refeeding syndrome. Nutrition 2001;17:632-7.

Friedli N, Stanga Z, Culkin A, Crook M, Laviano A, Sobotka L, et al. Management and prevention of refeeding syndrome in medical inpatients: An evidence-based and consensus-supported algorithm. Nutrition 2018;47:13-20.

Boateng AA, Sriram K, Meguid MM, Crook M. Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition 2010;26:156-67.

Coşkun R, Gündoğan K, Baldane S, Güven M, Sungur M. Refeeding hypophosphatemia: a potentially fatal danger in the intensive care unit. Turk J Med Sci 2014;44:369-74.

Fuentes E, Yeh DD, Quraishi SA, Johnson EA, Kaafarani H, Lee J, et al. Hypophosphatemia in Enterally Fed Patients in the Surgical Intensive Care Unit. Nutr Clin Pract 2017;32:252-7.

Aubry E, Friedli N, Schuetz P, Stanga Z. Refeeding syndrome in the frail elderly population: prevention, diagnosis and management. Clin Exp Gastroenterol 2018;11:255-64.

Olthof LE, Koekkoek WACK, van Setten C, Kars JCN, van Blokland D, van Zanten ARH. Impact of caloric intake in critically ill patients with, and without, refeeding syndrome: A retrospective study. Clin Nutr 2018;37:1609-17.

Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. BMJ 2008;336:1495-8.

McKnight CL, Newberry C, Sarav M, Martindale R, Hurt R, Daley B. Refeeding Syndrome in the Critically Ill: a Literature Review and Clinician’s Guide. Curr Gastroenterol Rep 2019;21:58.

Kraaijenbrink BV, Lambers WM, Mathus-Vliegen EM, Siegert CE. Incidence of refeeding syndrome in internal medicine patients. Neth J Med 2016;74:116-21.

Kagansky N, Levy S, Koren-Morag N, Berger D, Knobler H. Hypophosphataemia in old patients is associated with the refeeding syndrome and reduced survival. J Intern Med 2005;257:461-8.

Martínez MJ, Martínez MA, Montero M, Campelo E, Castro I, Inaraja MT. Hypophosphatemia in postoperative patients with total parenteral nutrition: influence of nutritional support teams. Nutr Hosp 2006;21:657-60.

González Avila G, Fajardo Rodríguez A, González Figueroa E. Incidencia de síndrome de realimentación en enfermos con cáncer que reciben tratamiento nutricio artificial [The incidence of the refeeding syndrome in cancer patients who receive artificial nutritional treatment]. Nutr Hosp 1996;11:98-101.

Ornstein RM, Golden NH, Jacobson MS, Shenker IR. Hypophosphatemia during nutritional rehabilitation in anorexia nervosa: implications for refeeding and monitoring. J Adolesc Health 2003;32:83-8.

Crook MA. Refeeding syndrome: problems with definition and management. Nutrition 2014;30:1448-55.

Kirkland LL, Kashiwagi DT, Brantley S, Scheurer D, Varkey P. Nutrition in the hospitalized patient. J Hosp Med 2013;8:52-8.

da Silva JSV, Seres DS, Sabino K, Adams SC, Berdahl GJ, Citty SW, et al. ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract 2020;35:178-95.

Sobotka L, editor. Basics in clinical nutrition. 5th ed. Prague: Galen; 2019.

National Institute for Health and Care Excellence (NICE). (2006). Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. NICE Clinical Guideline No. 32. February 2006.

Tresley J, Sheean PM. Refeeding syndrome: recognition is the key to prevention and management. J Am Diet Assoc 2008;108:2105-8.

Berger MM, Soguel L, Charrière M, Thériault B, Pralong F, Schaller MD. Impact of the reduction of the recommended energy target in the ICU on protein delivery and clinical outcomes. Clin Nutr 2017;36:281-7.

Friedli N, Baumann J, Hummel R, Kloter M, Odermatt J, Fehr R, et al. Refeeding syndrome is associated with increased mortality in malnourished medical inpatients: Secondary analysis of a randomized trial. Medicine (Baltimore) 2020;99:e18506.

Zeki S, Culkin A, Gabe SM, Nightingale JM. Refeeding hypophosphataemia is more common in enteral than parenteral feeding in adult in patients. Clin Nutr 2011;30:365-8.

Güçlü M, İmamoğlu Ş. Incretins and usage in clinical practice. Turkiye Klinikleri J Int Med Sci 2007;3:53-60.

Doig GS, Simpson F, Heighes PT, Bellomo R, Chesher D, Caterson ID, et al. 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. Lancet Respir Med 2015;3:943-52.

Dwyer K, Barone JE, Rogers JF. Severe hypophosphatemia in postoperative patients. Nutr Clin Pract 1992;7:279-83.

Taşöz R. Oğuz M. Eryılmaz S. Akalın H. Açık kalp cerrahisi sonrası hipofosfatemi gelişim ve solunum problemleri ile ilişkisi. GKD Cer Derg 1996;1:31-5.

The Factors That Cause Hypophosphatemia in Patients Receivig Clinical Nutrition Treatment

ABSTRACT

References