A case of refeeding syndrome during intradialytic parenteral nutrition

Abstract

BackgroundRefeeding syndrome is a potentially fatal electrolyte shift in patients with rapid feeding after low-calorie intake. Although the key to diagnosing refeeding syndrome is hypophosphatemia after feeding, renal dysfunction might hide refeeding hypophosphatemia, especially in maintenance hemodialysis patients. Intradialytic parenteral nutrition (IDPN) is a therapeutic approach used to treat malnourished patients with maintenance hemodialysis. No earlier report describes a study of refeeding syndrome complicated with IDPN.Case presentationWe present a case of a 77-year-old man undergoing maintenance hemodialysis for 17 years. While IDPN was administered after 10 days fasting, ventricular tachycardia (VT) occurred, possibly because of a rapid intracellular shift of potassium mainly explained as refeeding syndrome in addition to potassium removal by hemodialysis. A greater decline of serum phosphate concentrations during hemodialysis on that day compared with that during usual hemodialysis session supports our inference of the contribution of refeeding syndrome to VT complicated with hypokalemia.ConclusionPhysicians should know that IDPN can induce refeeding hypophosphatemia and rapid intracellular shift of potassium. Synergic lowering effects of serum potassium both with intracellular shift caused by refeeding syndrome and potassium removal by hemodialysis might cause lethal arrhythmia in patients treated with IDPN. Before treating malnourished patients with IDPN, the risk of refeeding syndrome should be assessed in patients with high risk of refeeding syndrome.