Refeeding syndrome is associated with increased mortality in malnourished medical inpatients

Abstract

Background: Whether the occurrence of refeeding syndrome (RFS), a metabolic condition characterized by electrolyte shifts after initiation of nutritional therapy, has a negative impact on clinical outcomes remains ill-defined. We prospectively investigated a subgroup of patients included in a multicentre, nutritional trial (EFFORT) for the occurrence of RFS. Methods: In this secondary analysis of a randomized-controlled trial investigating the effects of nutritional support in malnourished medical inpatients, we prospectively screened patients for RFS and classified them as “RFS confirmed” and “RFS not confirmed” based on predefined criteria (i.e. electrolyte shifts, clinical symptoms, clinical context, and patient history). We assessed associations of RFS and mortality within 180 days (primary endpoint) and other secondary endpoints using multivariable regression analysis. Results: Among 967 included patients, RFS was confirmed in 141 (14.6%) patients. Compared to patients with no evidence for RFS, patients with confirmed RFS had significantly increased 180-days mortality rates (42/141 (29.8%) vs 181/826 (21.9%), adjusted odds ratio (OR) 1.53 (95% CI 1.02 to 2.29), P < .05). Patients with RFS also had an increased risk for ICU admission (6/141 (4.3%) vs 13/826 (1.6%), adjusted OR 2.71 (95% CI 1.01 to 7.27), P < .05) and longer mean length of hospital stays (10.5 ± 6.9 vs 9.0 ± 6.6 days, adjusted difference 1.57 days (95% CI 0.38–2.75), P = .01). Conclusion: A relevant proportion of medical inpatients with malnutrition develop features of RFS upon hospital admission, which is associated with long-term mortality and other adverse clinical outcomes. Further studies are needed to develop preventive strategies for RFS in this patient population.

Management of Refeeding Syndrome in Medical Inpatients

“…confirmed RFS have significant mortality rates and increased non-elective hospital readmission, thus confirming the negative effect of RFS on clinical outcome [5,6].…”

“…A secondary analysis of a large randomized controlled trial (EFFORT trial [5]) showing the beneficial effects of nutritional support in hospitalized patients provides evidence that, due to the consequences of RFS (higher mortality and non-elective readmission rates), patients at risk may benefit from a specific treatment [5,6]. This secondary analysis relying on the risk stratification and definition from the above-mentioned experts' consensus [19] largely confirms the proposed risk factors and occurrence of RFS [6,8,12,19].…”

“…The awareness of the medical and nursing staff is often too low in clinical practice, leading to under-diagnosis of this complication, which often has an unspecific clinical presentation. This review provides important insights into the RFS, practical recommendations for the management of RFS in the medical inpatient population (excluding eating disorders) based on consensus opinion and on current evidence from clinical studies, including risk stratification, prevention, diagnosis, and management and monitoring of nutritional and fluid therapy.confirmed RFS have significant mortality rates and increased non-elective hospital readmission, thus confirming the negative effect of RFS on clinical outcome [5,6].Nutritional treatment is a central aspect of modern multimodal inpatient therapy. It aims to reduce complications and mortality rates, and to improve patients' quality of life and autonomy [5,7].…”

“…Due to the lack of large randomized trials, the current literature confirms the clinical consequences but not the efficacy of measures used to prevent and treat RFS. A recent secondary analysis of the EFFORT trial showed that RFS has a significant impact on mortality and readmission rate [5,6]. Therefore, prevention, detection, and early treatment of malnourished catabolic medical patients at risk of RFS is essential [25,47,52].…”

“…Patients at risk of developing RFS need replenishment of electrolytes and vitamins (especially thiamine) serum levels to help prevent/treat symptoms. In this study, the data from 967 malnourished patients were analyzed for RFS; 141 (14.6%) had confirmed RFS, indicating the high incidence of this metabolic state in medical patients receiving nutritional support [6]. The clinical manifestation can vary from mild forms with limited clinical signs and symptoms to severe forms with potentially lethal complications.…”