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.

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College Answer

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

Discussion

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.

Organ System Complications of Refeeding Syndrome

Cardiovascular:

  • Heart failure (overload) due to atrophy
  • Hypotension and shock
  • Cardiac arrhythmia

Gastrointestinal

  • LFT derangement due to acute fatty liver
  • Diarrhoea due to intestinal atrophy
  • Delayed gastric emptying
  • Arrhythmias

Renal

  • Acute tubular necrosis

 

Respiratory

  • Respiratory muscle weakness
  • Prolonged ventilator weaning

Musculoskeletal

  • Muscle weakness
  • Tetany
  • Rhabdomyolysis due to low phosphate

Neurological

  • Seizures
  • Coma
  • Delirium

Immunological

  • Phagocyte dysfunction
  • Increased susceptibility to sepsis
  •  
 

References

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).