Symptoms and General Pathology

All Conditions

Neoplasms

Nutritional and Metabolic Diseases

Syndrome

Head and Neck Neoplasms

Hypophosphatemia

Refeeding Syndrome

Hypokalemia

Potassium Deficiency

Malnutrition

Nutrition Disorders

Low sodium diet

Jens R. Andersen, MD, lektor

The study is based on a master thesis which showed that 72% of patients with head and neck cancer admitted to a Danish hospital (Rigshospitalet, Copenhagen) developed refeeding syndrome after admission.

Refeeding syndrome is characterized by a decrease in plasma phosphate levels, which develops after the reintroduction of an adequate food intake after a longer period of starvation or semi-starvation. This normally happens within 7 days after reintroduction of food.

The aim of this study is to minimize the incidence of refeeding syndrome in this group of patients by reintroducing food slowly and by providing a diet low in sodium and high in slowly absorbed carbohydrates as a prevention diet (i.e. given before a potential decrease in plasma phosphate levels appear). Both patients that eat normally, patients with eating tubes and patients with central vein catheters are included in the study, but the data will be evaluated both together and separately.

A large weight loss as a result of a longer period (\>30 days) of starvation or semi-starvation will result in a metabolic adaptation to the decreased food intake. To prevent the degradation of muscle mass into gluco- and ketogenic amino acids to be used for energy production, a shift from gluconeogenesis to lipolysis occurs. Lipids therefore become the primary energy fuel, and the body adapts to use ketone bodies instead of glucose. The reduction in glucose metabolism results in a decreased need for amino acids for use in gluconeogenesis. This means that less amino acids are needed for gluconeogenesis and therefore important muscle mass is preserved. At the same time as the lipid stores are degraded, an intracellular depletion of phosphate, potassium and magnesium occurs. The serum levels of these electrolytes stay within the normal range as long as the body is in the adaptive starvation state. A too quick reintroduction of food to the body will result in a major glucose-induced increase in insulin secretion that will stimulate the transport of glucose, phosphate, potassium and magnesium from plasma into the cells. Because the extracellular blood volume is much smaller than the intracellular, an influx of these electrolytes to the intracellular space will result in a quick and large decrease in the plasma levels. Likewise, an influx of glucose means that it again can enter the glucolysis, and the need for phosphate and the co-factor thiamine, for the production of ATP, will increase. The increased production of adenosine triphosphate (ATP) will activate membrane pumps and reestablish the membrane potential. This means that sodium will be transported from the large intracellular space to the small extracellular, with subsequent fluid retention and edema formation.

Therefore a slowly introduced diet low in sodium and high in slowly absorbed carbohydrates might prevent the development of refeeding syndrome.

The Effect of a Diet Based on Low Sodium and Slowly Absorbed Carbohydrates on the Incidence of Refeeding Syndrome in Patients With Head and Neck Cancer

The Prevention of Refeeding Syndrome by a Diet Regime in Patient With Head and Neck Cancer

Measured by changes in plasma cobalamin levels/vitamin B12 levels (pmol/L), plasma iron levels (μmol/L), plasma ferritin levels (μg/L), mean cell volume (MCV) (fL), plasma albumin levels (μmol/L), plasma alanine aminotransferase levels (ALAT) (U/L), plasma coagulation factors II, VII, X levels (INR), plasma c-reactive protein levels (nmol/L), hemoglobin levels (Hgb) (mmol/L), plasma sodium levels (mmol/L), plasma potassium levels (mmol/L), plasma creatinine levels (μmol/L), plasma carbamide levels (mmol/L), plasma folate levels (nmol/L), plasma zink levels (μmol/L), plasma magnesium levels (mmol/L) and plasma selenium levels (μg/L).

Measured by a decrease in plasma phosphate levels.

Measured by infection events recorded in the medical journal.

Measured by number of days in the hospital

Measured by number of days in the intensive-care unit

Measured by thrombosis events and other complications recorded in the medical journal

University of Copenhagen

Professor

Starvation

Gastrointestinal Agents

All Drugs and Chemicals

Herbal and Botanical

Pancrelipase

Pancreatin

Cola

Consecutive admissions - n= 43 - 34 operated (79%) - 10 patients acutely admitted Diseases in Esophagus (8), gastric cavity (8), pancreas (7), colon/rectum (8), bile (4), small intestine (3), IBD (5) No interventions in the treatments, just observation

Consecutive admissions - n=8 - 7 radiation therapy - 1 operated Locations: 2 Larynx, 1 oro-pharynx, 4 tonsillar, 1 tung No interventions in the treatments, just observation

observation

jens R Andersen, MD, MPA

The incidence and main risk-factors analyzed in consecutive in-patients in the departments og gastroenterology and ear-nose and throat diseases (cancer in radiation therapy)

Patients with either parenteral- or tube feeding enter the study to assure sufficient nutrition.

During hospitalization patients were monitored with daily blood samples and clinical evaluation of symptoms in addition to the coverage of energy and protein in percent of estimated needs.

Refeeding phenomenon was defined as a decrease in plasma phosphate after the initiation of nutrition.

Refeeding syndrome as refeeding phenomenon and one or more relevant symptoms in addition (hypotension, cardiac arrhythmia, edema, confusion)

Incidence of Refeeding Syndrome in Consecutively Admitted Patients

Refeeding Syndrome - Incidence and Risk Factors: An Observational Study on Patients With G-I Disease and Head-neck Cancer

No. patients with decrease in plasma phosphate + clinical symptoms

No. patients with decrease in plasma phosphate after start of nutrition

St. Olavs Hospital

Jens Rikardt Andersen

Assoc Prof

Critical Illness

Disease Attributes

Micronutrients

Vitamins

Thiamine

Thiamin

Vitamin B1

Patients will undergo a caloric management protocol:

Days 1 and 2:

1. Reduction of caloric intake to 5kcal/kg/day;
2. Replacement of serum phosforus, potassium and magnesium;
3. Administration of 100mg intravenous thiamine, vitamins and microelements.

From day 3:

1. If serum phosphorus \< 2.5mg/dL, protocol will be followed according to day 2;
2. If serum phosphorus \> 2.5mg/dL, a gradual increase to target caloric intake will ensue.

1. Nutritional management will be followed according to institutional protocol.
2. Electrolyte replacement will be provided at the clinician's discretion.

Strategy based on reduction of nutritional intake and electrolyte replacement.

Caloric Management Protocol

Ludhmila A Hajjar, MD, PhD

Eduardo A Osawa, MD, PhD

Ilana Roitman

Clarice H Park, MD, PhD

Gisele Queiroz, MD

The purpose of this study is to evaluate whether a nutritional strategy is effective in critically ill patients with cancer diagnosed with refeeding syndrome.

Refeeding syndrome is a clinical entity triggered by the introduction of calories in chronically undernourished patients. A number of organs may be affected due to imbalance of fluids and electrolytes. In the intensive care setting, there are no formal guidelines to recommend the appropriate treatment of this condition. The aim of this study is to evaluate the implementation of a nutritional protocol to address cancer patients admitted to the ICU with refeeding syndrome.

Refeeding Syndrome in Cancer Patients

Refeeding Syndrome in Cancer Patients Admitted to Adult Intensive Care Unit

Score of the number and severity of organ failures during ICU stay

Incidence of acute ischemic event or acute heart failure

Incidence of delirium according to CAM-ICU

Incidence of acute kidney injury according to KDIGO

Number of days in renal replacement therapy

Number of episodes of the following events: hypoglycemia, diarrhea, ileous, nausea and vomiting.

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
The Effect of a Diet Based on Low Sodium and Slowly Absorbed Carbohydrates on the Incidence of Refeeding Syndrome in Patients With Head and Neck Cancer	NCT01845922	Refeeding Syndr...	Low sodium diet	18 Years -	University of Copenhagen
Incidence of Refeeding Syndrome in Consecutively Admitted Patients	NCT05967858	Refeeding Syndr... Starvation Phosphate Defic...	observation	18 Years -	University of Copenhagen
Refeeding Syndrome in Cancer Patients	NCT02534181	Refeeding Syndr... Cancer Critical Illnes...	Caloric Managem...	18 Years -	University of Sao Paulo
Incidence of Refeeding Syndrome in Consecutively Admitted Patients	NCT05967858	Refeeding Syndr... Starvation Phosphate Defic...	observation	18 Years -	University of Copenhagen
Refeeding Syndrome in Cancer Patients	NCT02534181	Refeeding Syndr... Cancer Critical Illnes...	Caloric Managem...	18 Years -	University of Sao Paulo
Refeeding Syndrome in Cancer Patients	NCT02534181	Refeeding Syndr... Cancer Critical Illnes...	Caloric Managem...	18 Years -	University of Sao Paulo

Spots Global Cancer Trial Database for refeeding syndrome