A 73 year old man, body mass index 17.5 kg/m2, is commenced on total parenteral nutrition (TPN) following surgery for a gastric malignancy. Four days later he develops increasing breathlessness and hypotension. Blood results are as follows:
Test |
Value |
Normal Range |
Haemoglobin* |
109 G/L |
135 – 180 |
White Cell Count* |
13.6 x 109/L |
4.0 – 11.0 |
Platelets |
178 x 109/L |
150 – 400 |
Urea* |
10.3 mmol/L |
3.0 – 8.0 |
Creatinine |
84 µ mol/L |
45 – 90 |
Sodium |
145 mmol/L |
134 – 146 |
Potassium* |
1.8 mmol/L |
3.4 – 5.0 |
Chloride* |
115 mmol/l |
98 – 108 |
Bicarbonate* |
14 mmol/L |
22 – 32 |
Calcium (albumin adjusted)* |
1.82 mmol/L |
2.15 – 2.6 |
Albumin* |
26 G/L |
35 – 50 |
Magnesium* |
0.41 mmol/L |
0.7 – 1.1 |
Phosphate inorganic* |
0.26 mmol/L |
0.8 – 1.5 |
Glucose* |
18.6 mmol/L |
3.0 – 5.4 |
a) What is the likely diagnosis? Provide 4 reasons which support your answer.
b) Give 5 associated complications.
a) What is the likely diagnosis? Provide 4 reasons which support your answer.
Refeeding syndrome (Nutritional recovery syndrome) Clinical history, Low Po4, K 1.8 and Mg
b) Give 5 associated complications.
Respiratory
Respiratory failure
Respiratory muscle weakness
Cardiac
Cardiac failure / Cardiomyopathy
Hypotension
Arrhythmias
Neurologic
Altered mental state
Paraesthesiae
Seizures
Renal
Acute tubular necrosis
Skeletal
Rhabdomyolysis
Weakness
Endocrine
Insulin resistance
Osteomalacia
Haematologic
White cell dysfunction
Thrombocytopenia / decreased platelet function
Haemolytic anaemia
Immune function
Sepsis
It is difficult to mistake refeeding syndrome. One if forced into this conclusion by the constellation of low potassium, low phosphate and low magnesium, in the context of recently recommenced nutrition.
Refeeding syndrome is discussed in greater detail elsewhere.
The complications are detailed in a large table, which I reproduce below.
Cardiovascular:
Gastrointestinal
Renal
|
Respiratory
Musculoskeletal
Neurological
Immunological
|
Hearing, Stephen D. "Refeeding syndrome." BMJ 328.7445 (2004): 908-909.
Stanga, Z., et al. "Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment." European journal of clinical nutrition 62.6 (2008): 687-694.
Kraft, Michael D., Imad F. Btaiche, and Gordon S. Sacks. "Review of the refeeding syndrome." Nutrition in Clinical Practice 20.6 (2005): 625-633.
Khan, Laeeq UR, et al. "Refeeding syndrome: a literature review."Gastroenterology research and practice 2011 (2010).