Refeeding Syndrome

Definition: The metabolic abnormalities that occur upon refeeding a person in a starved
state (Figure 1).
Metabolic consequences include:

Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Fluid balance abnormalities

The metabolic abnormalities can lead to significant pathophysiological consequences.

Pathophysiological consequences include:

Cardiac failure
Respiratory failure
Neuromuscular failure
Renal failure
Haematological failure
Hepatic failure
Gastrointestinal system failure

As thiamine acts as a coenzyme in carbohydrate metabolism, the symptoms of Wernikes

encephalopathy can occur by refeeding carbohydrate to a vitamin B depleted patient.
Figure 1. The Pathogenesis of Refeeding Syndrome

REFEEDING
Conversion to glucose as major energy source
Insulin release*
cellular glucose uptake, protein synthesis
Intracellular shifts and extracellular depletion of phosphate, potassium and
magnesium

Clinical symptoms of refeeding syndrome

* Insulin release stimulates the Na+K+ATPase pump. This drives potassium into the cells and
sodium moves out. Carbohydrate load and insulin release stimulate phosphate shifts into the
cells and phosphate depletion is associated with increased urinary magnesium excretionlow
extracellular phosphate, magnesium and potassium.
Who is at risk of refeeding syndrome?
Patients at risk of refeeding syndrome include:

Chronic alcoholics
Drug abusers
The chronically malnourished (particularly older people)
Patients with anorexia nervosa
Patients with prolonged nil by mouth or fasting times coupled with depletion or
physiological stres.

The risk of an individual patient for refeeding syndrome has been further classified:
Moderate Risk
Patient has one or more of the following:
1. BMI less than 18.5kg/m2
2. Unintentional weight loss greater than 10% within the previous 3-6 months
3. Very little intake for greater than 5 days
High Risk
Patient has one or more of the following:
1.
2.
3.
4.

BMI less than 16kg/m2

Unintentional weight loss greater than 15% within the previous 3-6 months
Very little nutritional intake for greater than 10 days
Low levels of potassium, phosphate or magnesium prior to feeding

Or patient has two or more of the following:

1.
2.
3.
4.

BMI less than 18.5kg/m2

Unintentional weight loss greater than 10% within the previous 3-6 months
Those with very little intake for greater than 5 days
A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics

Severely High Risk

Patient has both of the following

1. BMI less than 14
2. Negligible intake for greater than 15 days

How to start feeding in those at risk of re-feeding

The overall aim is to start refeeding slowly, supplement thiamine and aggressively replace any
electrolyte disturbances. Start enteral nutrition early (<24hrs post admission to ICU) in those
haemodynamically stable and who have a functioning gastrointestinal tract. Parenteral
nutrition should be started only if unable to meet nutritional requirements via the enteral route
(Figure 2).
Figure 2. Example of a refeeding syndrome flow chart
Determine level of re-feeding risk
Check baseline potassium, calcium, phosphate and magnesium levels
Replete electrolytes as indicated

Replete thiamine
Start feeding at 20 kcal/kg Moderate Risk
Start feeding at 10kcals/kg High Risk
Start feeding at 5kcal/kg

Severely High Risk

Do not wait for electrolyte blood level to be within normal range before slowly starting feeding

Repeat potassium, magnesium, calcium and phosphate levels 6-12hrs after initiation of
feeding

Replace electrolytes as required. If patient requires more than 2 electrolyte replacements

check urinary (24hour collection) magnesium, phosphate and potassium . Inform Dietician to
alter feed rate as required

Monitor potassium, magnesium, phosphate and calcium daily for 1st 3 days or until levels
within normal ranges, then 3 times a week for 2 weeks

MONITORING the severely at risk Restore circulatory volume and monitor fluid
balance and overall clinical status closely. Monitor cardiac rhythm continually in
these patients and any other who develop cardiac arrhythmias (NICE 2006)

References and further reading

Kraft M, Btaiche I and Sacks G. Review of the Refeeding Syndrome Nutr Clin Pract 2005; 20;
625.
Hearing SD. Refeeding syndrome. BMJ 2004; 328: 908-9.