Refeeding Hypophosphatemia Research Articles

Refeeding hypophosphatemia is a common cause of delirium in critically ill patients: A retrospective study

BackgroundThe purpose was to explore the correlation between refeeding hypophosphatemia and delirium and analyze the related factors in critically ill patients. MethodsWe conducted a retrospective review of critically ill patients admitted to Nanjing Drum Tower Hospital between September 2019 and March 2021. The patients were divided into delirium and nondelirium groups. Demographic data, underlying diseases, laboratory findings, comorbidities, nutritional intake and overall prognosis were collected and analyzed. ResultsIn total, 162 patients were included and divided into delirium (n = 54) and nondelirium (n = 108) groups. Serum phosphorus levels in the two groups decreased significantly in the first three days (P1, P2, P3) after nutrient intake compared with baseline before nutrient intake (Ppre). P1 and P2 were significantly lower in the delirium group compared to the nondelirium group. The maximum blood phosphorus reduction (Pmax) in the first three days after nutrient intake was significantly higher in the delirium group than in the nondelirium group. The time of Pmax in the delirium group was on the first day after nutrient intake. Multivariable logistic regression analysis identified starting route of nutrition and P1< 0.845 mmol/L as the independent predictors of delirium development in critically ill patients. ConclusionThe incidence of delirium in critically ill patients is high and associated with refeeding hypophosphatemia. Delirium may occur with serum phosphorus levels less than 0.845 mmol/L on the first day.

Frequency and Related Risk Factors of Refeeding Hypophosphatemia in Patients with Liver Cirrhosis: A Pilot Study.

Refeeding hypophosphatemia (RH) is associated with poor clinical outcomes and mortality. The presence of RH in patients with liver cirrhosis remains unclear. This study aims to determine the frequency of RH related to nutritional status and disease severity in liver cirrhosis. This study was prospectively conducted in a-single center gastroenterology clinic. Malnutrition was identified by Subjective Global Assessment (SGA). The disease severity was defined using Child score and MELD score. Serum phosphate levels <2.0 mg/dl are defined as hypophosphatemia. Twelve of 50 cirrhotic patients (24%) had RH during hospitalization. The most common RH was determined in 4 patients on day 4 during study follow up. The sharpest decline of serum phosphate levels was on day 4 (median: 2.3mg/dL). The Child score and MELD score were not significantly different between RH and Non-RH groups (p>0.05). The rate of malnutrition according to SGA was 56.0%. A total of 82%, 4%, 8%, and 4% of participants received regular diet and oral nutritional supplements, only enteral tube feeding, only parenteral nutrition, and combined enteral and parenteral nutrition, respectively. In the RH group, 32% of participants received only parenteral nutrition and had a higher presence of RH than patients receiving only oral or enteral tube feding (p<0.05). RH developed in ¼ of the study participants. This study also showed that artificial feeding carries a significant risk in terms of RH. Malnourished patients with liver cirrhosis receiving parenteral nutrition, closely monitored regarding high risk of RH.

Evaluation Of Refeeding Hypophosphatemia Frequency, Risk Factors And Nutritional Status During Stem Cell Transplantation In Patients With Hematologic Malignancy

Evaluation Of Refeeding Hypophosphatemia Frequency, Risk Factors And Nutritional Status During Stem Cell Transplantation In Patients With Hematologic Malignancy

The Frequency Of Refeeding Hypophosphatemia Patients With Solid Organ Tumors In Medical Oncology Clinics

The Frequency Of Refeeding Hypophosphatemia Patients With Solid Organ Tumors In Medical Oncology Clinics

Macronutrient intake and outcomes of ICU patients with refeeding hypophosphatemia

Normocaloric vs. calorie-restricted feeding in Intensive Care Unit (ICU) patients with refeeding hypophosphatemia (RH) is associated with increased mortality rates. Until now, only total energy provision has been studied. Data on individual macronutrients (proteins, lipids, and carbohydrates) and clinical outcomes are lacking. This study evaluates associations between macronutrient intake among RH patients during the first week of ICU admission and clinical outcomes. A single-centre retrospective observational cohort study was conducted among prolonged mechanically ventilated RH ICU patients. The primary outcome was the association of separate macronutrient intakes during the first week of ICU admission with 6-month mortality, adjusted for relevant variables. Other parameters included ICU-, hospital- and 3-month mortality, mechanical ventilation duration and length of ICU and hospital stay. Macronutrient intakes were subsequently analyzed during day 1-3 and day 4-7 of ICU admission. In total, 178 RH patients were included. Six-month all-cause mortality was 29.8%. Higher protein intake during days 1-3 of ICU admission (>0.71g/kg∗day; HR 2.224, 95%CI 1.261-3.923, p=0.006), higher age (HR 1.040, 95%CI 1.015-1.066, p=0.002) and higher APACHE II scores on ICU admission (HR 1.086, 95%CI 1.034-1.140, p=0.001) were associated with increased 6-month mortality. No differences in other outcomes were observed. High protein - not carbohydrate or lipid - intake during the first three days of ICU admission in patients with RH is associated with increased 6-month mortality, but not short-term outcomes. We hypothesize a time-dependent and dose-response relationship between protein intake and mortality in refeeding hypophosphatemia ICU patients, although additional (randomized controlled) studies are needed to confirm this hypothesis.

Impact of Nutritional Management on Survival of Critically Ill Malnourished Patients with Refeeding Hypophosphatemia

Early nutritional therapy may aggravate hypophosphatemia in critically ill patients. To investigate the influence of the type nutritional therapy on the survival of critically-ill malnourished patients at refeeding hypophosphatemia risk. Retrospective cohort study including malnourished, critically-ill adults, admitted from June 2014-December 2017 in an intensive care unit (ICU) at a tertiary hospital. Refeeding hypophosphatemia risk was defined as low serum phosphorus levels (<2.5 mg/dL) seen at two timepoints: before the initiation and at day 4 of the nutritional therapy. Patients receiving enteral nutrition (EN) were compared with those receiving supplemental parenteral nutrition (SPN-EN plus parenteral nutrition). Primary outcome was 60 d survival. Secondary endpoint was the incidence of refeeding hypophosphatemia risk. We included 468-321 patients (68.6%) received EN and 147 (31.4%) received SPN. The mortality rate was 36.3% (n=170). Refeeding hypophosphatemia risk was found in 116 (24.8%) patients before and in 177 (37.8%) at day 4 of nutritional therapy. The 60 d mean survival probability was greater for patients receiving SPN both before (42.4 vs. 22.4%, p=0.005) and at day 4 (37.4 vs. 25.8%, p=0.014) vs. patients receiving EN at the same timepoints. Cox regression showed a hazard ratio of 3.3 and 2.4 for patients at refeeding hypophosphatemia risk before and at day 4 of EN, respectively, compared to the SPN group at the same timepoints. Refeeding hypophosphatemia risk was frequent in malnourished ICU patients and the survival for patients receiving SPN seemed associated with better survival than EN only.

Evaluation of refeeding hypophosphatemia frequency, risk factors, and nutritional status during stem cell transplantation in patients with hematologic malignancy.

Refeeding Hypophosphatemia (RH) occurs with feeding after an extended period of not feeding. Hematological Stem Cell Transplantation (HSCT) is one of the effective methods for hematologic malignancy. Nutritional disorders are frequently observed in hematologic malignancies due to the disease's pathology and the treatment's effect. The study aims to determine the influencing factors by determining the frequency of RH in patients treated with HSCT. The study was conducted prospectively and randomly with 50 patients treated with HSCT for the first time. The study followed patients for 22 days, seven days before, and 14 days after. During the follow-up, data such as Scored Patient-Generated Subjective Global Assessment (PG-SGA), weight changes, nausea, vomiting, diarrhea, mucositis, infection and Graft Versus Host Disease development, need for intensive care, and 12-month mortality were recorded. RH states were evaluated during treatment. RH developed in 78% of patients treated with HSCT. Pre-transplantation PGSGA score, frequency of vomiting, and development of infection were higher in patients with RH (p<0.05). The patients had a mean weight loss of 2.9% after transplantation. Pre-transplantation, 88% of patients were well-nourished (PGSGA 0-3), post-transplantation, 70% of patients were moderately undernourished (PGSGA 4-8), and 30% were severely malnourished (PGSGA ≥ 9). While total protein and albumin decreased after transplantation, CRP increased (p<0.05). According to multivariate logistic regression analysis, infection (95% CI: 1.375-61.379, p=0.022) and pre-transplant PGSGA (95% CI: 1.035-45.454, p=0.046) independently affect RH development. RH was detected at a high rate in patients treated with HSCT. Elevated risk of malnutrition before transplantation, frequency of vomiting, and development of infection were determined as factors affecting RH development.

Early hypophosphatemia in critically ill children and the effect of parenteral nutrition: A secondary analysis of the PEPaNIC RCT

Hypophosphatemia during critical illness has been associated with adverse outcome. The reintroduction of enteral or parenteral nutrition, leading to refeeding hypophosphatemia (RFH), has been presented as potential risk factor. We investigated the occurrence of early RFH, its association with clinical outcome, and the impact of early parenteral nutrition (PN) on the development of early RFH in pediatric critical illness. This is a secondary analysis of the PEPaNIC randomized controlled trial (N=1440), which showed that withholding supplemental parenteral nutrition (PN) for 1 week (late-PN) in the pediatric intensive care unit (PICU) accelerated recovery and reduced new infections compared to early-PN (<24h). Patients with renal replacement therapy or unavailable phosphate concentrations were excluded from this analysis. Early RFH was defined as serum/plasma phosphate <0.65mmol/L and a drop of >0.16mmol/L within 3 days of admission to the PICU. The association between baseline characteristics and early RFH, and the association of early RFH with clinical outcome were investigated using logistic and linear regression models, both uncorrected and corrected for possible confounders. To examine the impact of nutritional intake on phosphate concentrations, structural nested mean models with propensity score and censoring models were used. A total of 1247 patients were eligible (618 early-PN, 629 late-PN). Early RFH occurred in 40 patients (3%) in total, significantly more in the early-PN group (n=31, within-group occurrence 5%) than in the late-PN-group (n=9, within-group occurrence 1%, p<0.001). Patients who were older (OR 1.14 (95% CI 1.08; 1.21) per year added, p<0.001) and who had a higher Pediatric Risk of Mortality (PIM3) score had a higher risk of developing early RFH (OR 1.36 (95% CI 1.15; 1.59) per unit added, p<0.001), whereas patients in the late-PN group had a lower risk of early RFH (OR 0.24 (95% CI 0.10; 0.49), p<0.001). Early RFH was significantly associated with a 56% longer PICU stay (p=0.003) and 42% longer hospital stay (p=0.007), but not with new infections (OR 2.01 (95% CI 0.90; 4.30), p=0.08) or length of mechanical ventilatory support (OR 1.05 (95% CI-3.92; 6.03), p=0.68), when adjusted for possible confounders. Increase of parenteral nutrition intake (in % kcal of predicted resting energy expenditure) decreased phosphate concentrations (c=-0.002 (95% CI -0.002;-0.001). Early RFH occurred in 3% of critically ill children. Patients randomized to late-PN had a lower chance of developing early RFH, which may be explained by the more gradual build-up of nutrition. As early RFH might impact recovery, it is important to closely monitor phosphate concentrations in patients, especially of those at risk for early RFH.

Comparison of a low carbohydrate intake and standard carbohydrate intake on refeeding hypophosphatemia in children and adolescents with anorexia nervosa: a pilot randomised controlled trial

BackgroundNutritional rehabilitation for patients with anorexia nervosa involves balancing the need for weight gain whilst mitigating the risk of refeeding syndrome. Graded caloric increases and restriction of calories from carbohydrate have been used to minimise the risk of developing refeeding hypophosphatemia. There is little evidence to support the recommended nutrient composition, specifically the recommended carbohydrate intake that is safe in this population. The aim of this pilot study was to compare the effect of a low and a standard carbohydrate feeding protocol on serum phosphate levels in children and adolescents with anorexia nervosa.MethodsA pilot study of 23 children and adolescents with anorexia nervosa admitted for medical stabilisation to the adolescent ward of a tertiary hospital was undertaken. Participants were commenced on an oral feeding protocol and were randomly allocated to isocaloric meal plans that were either low carbohydrate (< 40% total energy from carbohydrate) or standard carbohydrate (50–60% total energy from carbohydrate). Serum phosphate levels were monitored daily across the first week and twice weekly thereafter. Clinical status, including weight gain, was monitored throughout admission.Results52% (n = 12) of participants were allocated to the low carbohydrate group and 48% (n = 11) were allocated to the standard carbohydrate group. No patients in either of the diet groups developed refeeding hypophosphatemia in the first seven days of admission. Weight gain during the first week was significantly higher in the standard carbohydrate diet (1.4 kg/wk ± 0.5) compared to the low carbohydrate diet (0.6 kg/wk ± 0.9), p value 0.03. Participants from both diet groups were largely orally fed with less than 10% of the total number of meals and/or snacks across both groups provided as nutrition supplement drinks, either orally or enterally.ConclusionThis pilot study supports that a standard carbohydrate intake (providing 50–60% of total energy from carbohydrate) optimises nutritional rehabilitation without increasing the risk of refeeding hypophosphatemia in adolescent inpatients with anorexia nervosa.CTN: ACTRN12621000300875.Plain English Summary: People with eating disorders who are underweight or malnourished, such as patients with anorexia nervosa, are at risk of refeeding syndrome when they receive treatment and return to regular eating. Refeeding syndrome may cause fluid and electrolyte shifts. This can occur as a result of the reintroduction of carbohydrates, and can have potentially life-threatening consequences if not managed appropriately. Refeeding hypophosphatemia is one of the early markers of refeeding syndrome. This study compared patients who were provided a low carbohydrate diet (40% total energy from carbohydrate) to those who were provided a standard carbohydrate diet (50–60% total energy from carbohydrate) to see if patients from either group were more at risk of developing refeeding syndrome. No patients in either of the diet groups developed refeeding hypophosphatemia. This pilot study may help to ensure that when patients get treated for their eating disorder in hospital, they can return to a normal diet as soon as possible with close medical monitoring.

Prophylactic supplementation of phosphate, magnesium, and potassium for the prevention of refeeding syndrome in hospitalized individuals with anorexia nervosa.

Medical stabilization, nutrition rehabilitation, and weight restoration, while minimizing risk for the potentially fatal complication of refeeding syndrome, are the primary goals for the treatment of hospitalized individuals with anorexia nervosa and other restrictive-type eating disorders. The purpose of this review was to examine the literature exploring the prophylactic supplementation of phosphate, magnesium, and potassium, in addition to routine thiamin and multivitamin supplementation, for the prevention of refeeding syndrome in adolescents and adults with anorexia nervosa. Through evaluation of outcomes (including serum electrolyte levels and clinical signs and symptoms such as respiratory failure, cardiac failure, peripheral edema, rhabdomyolysis, and encephalopathy), three studies found that prophylactic supplementation of potassium, magnesium, and/or phosphate were effective in preventing refeeding syndrome or refeeding hypophosphatemia (a characteristic of refeeding syndrome). Although all studies found that prophylactic supplementation was effective in preventing refeeding syndrome, refeeding approaches (including the method, amount, and duration of nutrient delivery) as well as the populations studied varied considerably, making it difficult to arrive at specific recommendations for practice. Randomized controlled trials are needed to further examine the safety and effectiveness of prophylactic supplementation of phosphate, magnesium, and potassium on the prevention of refeeding syndrome, utilizing similar feeding and supplementation protocols.

Explainable machine learning model to predict refeeding hypophosphatemia.

Refeeding syndrome (RFS) is a disease that occurs when feeding is restarted and metabolism changes from catabolic to anabolic status. RFS can manifest variously, ranging from asymptomatic to fatal, therefore it may easily be overlooked. RFS prediction using explainable machine learning can improve diagnosis and treatment. Our study aimed to propose a machine learning model for RFS prediction, specifically refeeding hypophosphatemia, to evaluate its performance compared with conventional regression models, and to explain the machine learning classification through Shapley additive explanations (SHAP) values. A retrospective study was conducted including 806 patients, with 2 or more days of nothing-by-mouth prescription, and with phosphate (P) level measurements within 5 days of refeeding were selected. We divided the patients into hypophosphatemia (n=367) and non-hypophosphatemia groups (n=439) at a P level of 0.8mmol/L. Among the features examined within 48h after admission, we reviewed laboratory test results and electronic medical records. Logistic, Lasso, and ridge regressions were used as conventional models, and performances were compared with our extreme gradient boosting (XGBoost) machine learning model using the area under the receiver operating characteristic curve. Our model was explained using the SHAP value. The areas under the curve were 0.950 (95% confidence interval: 0.924-0.975) for our XGBoost machine learning model and surpassed the performance of conventional regression models; 0.760 (0.707-0.813) for logistic regression, 0.751 (0.694-0.807) for Lasso regression, and 0.758 (0.701-0.809) for ridge regression. According to the SHAP values in the order of importance, low initial P, recent weight loss, high creatinine, diabetes mellitus with insulin use, low haemoglobin A1c, furosemide use, intensive care unit admission, blood urea nitrogen level of 19-65, parenteral nutrition, magnesium below or above the normal range, low potassium, and older age were features to predict refeeding hypophosphatemia. The machine learning model for predicting RFS has a substantially higher effectiveness than conventional regression methods. Creating an accurate risk assessment tool based on machine learning for early identification of patients at risk for RFS can enable careful nutrition management planning and monitoring in the intensive care unit, towards reducing the incidence of RFS-related morbidity and mortality.

Factors associated with refeeding hypophosphatemia in adolescents and young adults hospitalized with anorexia nervosa.

Refeeding hypophosphatemia (RH) in individuals with anorexia nervosa (AN) is a potentially fatal complication of nutrition restoration; yet, little is known about risk. This retrospective cohort study examined factors found in hospitalized youth with AN that may contribute to RH. We reviewed medical records of 300 individuals diagnosed with AN admitted between the years of 2010 and 2016. Logistic regression examined factors associated with RH. Multivariate regression examined factors associated with phosphorus nadir. For 300 participants, the mean (SD) age was 15.5 (2.5) years, 88.3% were White, and 88.3% were female. Participants lost an average of 11.3 (9.7) kg of body weight and were 82% (12.1) of median body mass index (BMI). Age (P = .022), nasogastric (NG) tube feeding (P = .054), weight gain (P = .003), potassium level (P = .001), and magnesium level (P = .024) were contributors to RH. Odds of RH were 13.7 times higher for each unit reduction in magnesium, 9.2 times higher for each unit reduction in potassium, three times higher in those who received NG feeding, 1.5 times higher for each kg of weight gain, and 1.2 times higher for each year of age. Regarding phosphorus nadir, serum magnesium level (P < .001) and admission BMI (P = .002) contributed significantly. The results indicate that age, NG feeding, weight gain, electrolyte abnormalities, and BMI on admission are potential indicators of the development of RH in youth. This study identifies clinical risk factors associated with RH and may guide further investigation.

Refeeding Patients with Moderate and Severe Eating Disorders: A Retrospective Cohort Study

Background: Anorexia Nervosa (AN) is a life-threatening mental illness that can cause significant medical complications, including the potentially fatal refeeding syndrome. Registered dietitians (RDs) are a critical part of an eating disorder multidisciplinary team that focuses treatment on safe weight restoration and nutrition rehabilitation. Method: This study is a description of how the nutrition rehabilitation protocol of 395 adult patients diagnosed with AN and admitted to residential eating disorder treatment is implemented, how the protocol is sustained throughout a patient’s treatment stay to achieve desired weight gain, and how the patients’ biochemical and clinical progress proceeded between admission and discharge, including laboratory results and body mass index (BMI). Results: One hundred twenty-six patients required phosphorus supplementation for refeeding hypophosphatemia (RH); admission BMI was not significantly different between those with and without RH. The 15% of patients who required enteral nutrition at any point during their admission gained significantly less weight than patients who only received an oral meal plan. 34.4% of patients admitted with starvation induced hepatitis, 28.6% experienced refeeding hepatitis at some point, 21.0% of patients had elevated liver function tests 2 weeks into refeeding and 28.6% at discharge. Conclusions: This study demonstrated overall effectiveness in achieving weight restoration goals with aggressive kcal increases without a single incidence of refeeding syndrome and infrequent RH. No significant biochemical changes were observed during refeeding. With close medical supervision and concurrent RD oversight, a refeeding approach with consistent calorie increases that is more aggressive than previously recommended appears to be safe.

The incidence of the refeeding syndrome. A systematic review and meta-analyses of literature

The refeeding syndrome (RFS) has been recognized as a potentially life-threatening metabolic complication of re-nutrition, but the definition widely varies and, its incidence is unknown. The aim of this systematic review and meta-analyses was to estimate the incidence of RFS in adults by considering the definition used by the authors as well as the recent criteria proposed by the American Society of Parenteral and Enteral Nutrition (ASPEN) consensus. Furthermore, the incidence of refeeding hypophosphatemia (RH) was also assessed. Four databases were systematically searched until September 2020 for retrieving trials and observational studies. The incidences of RFS and RH were expressed as percentage and reported with 95% confidence intervals (CI). Thirty-five observational studies were included in the analysis. The risk of bias was serious in 16 studies and moderate in the remaining 19. The incidence of RFS varied from 0% to 62% across the studies. No substantial change in the originally reported incidence of RFS was found by applying the ASPEN criteria. Similarly, the incidence of RH ranged between 7% and 62%. In the subgroup analyses, inpatients from Intensive Care Units (ICUs) and those initially fed with >20kcal/kg/day seemed to have a higher incidence of both RFS (pooled incidence=44%; 95% CI 36%-52%) and RH (pooled incidence=27%; 95% CI 21%-34%). However, due to the high heterogeneity of data, summary incidence measures are meaningless. The incidence rate of both RFS and RH greatly varied according to the definition used and the population analyzed, being higher in ICU inpatients and in those with increased initial caloric supply. Therefore, a universally accepted definition for RFS, taking different clinical contexts and groups of patients into account, is still needed to better characterize the syndrome and its approach.

Body mass index and blood urea nitrogen to creatinine ratio predicts refeeding hypophosphatemia of anorexia nervosa patients with severe malnutrition

AimTo investigate development of refeeding hypophosphatemia during the refeeding period and the extent of the decrease in the serum phosphorus level among anorexia nervosa patients with severe malnutrition.ObjectiveThe accurate prediction of the severity of refeeding hypophosphatemia in patients with anorexia nervosa during acute treatment is of great importance. Although some predictors were found in previous reports, these studies used binominal data—the presence or absence of hypophosphatemia—as an outcome indicator but not the extent of serum phosphorus level decrease. It is crucial in clinical settings to predict the extent of the serum phosphorus level decrease as well as development of refeeding hypophosphatemia, in particular, for patients with severe malnutrition, who has a higher risk of death.MethodsWe investigated 63 admissions from 37 patients with anorexia nervosa who had severe malnutrition (admission body mass index 11.5 ± 1.6) and carried out a linear discriminant regression analysis for the development of refeeding hypophosphatemia. The extent of the decrease in the serum phosphorus level were investigated using multiple linear regression analysis. Explanatory variables included data upon admission (age, sex, body mass index, blood urea nitrogen to creatinine ratio, albumin, initial serum phosphorus level, anorexia nervosa type, i.e., restrictive or binge-purge) as well as treatment-related indicators (calorie intake, amount of phosphate administered, and rate of weight gain).ResultsDevelopment of refeeding hypophosphatemia and a change in serum phosphorus levels were predicted by body mass index and elevated blood urea nitrogen to creatinine ratio.ConclusionsOur study found that refeeding hypophosphatemia among patients with severe malnutrition was predicted by a lower body mass index and elevated blood urea nitrogen to creatinine ratio.

Diets with high carbohydrate contents were associated with refeeding hypophosphatemia: A retrospective study in Japanese inpatients with anorexia nervosa.

Refeeding hypophosphatemia (RH) is a potentially fatal complication in patients with anorexia nervosa (AN), and its dietary preventive strategy is not well established. We aimed to examine the association between carbohydrate content in the diet and the occurrence of RH in inpatients with AN via retrospective medical chart review. We performed a chart review to collect data of patients with AN hospitalized at the Department of Psychosomatic Medicine of the University of Tokyo Hospital between April 1, 2012, and February 29, 2020. Receiver operating characteristic (ROC) analysis was performed to determine the cutoff point of the percentage of carbohydrate content in the diet for the occurrence of RH. Multivariate logistic regression analysis was performed with occurrence of RH as the dependent variable and the carbohydrate content of more than the identified cutoff point as the independent variable adjusting for the risk factors for RH. The percentage of carbohydrate content that is higher than the cutoff point obtained from the ROC analysis (58.4%) was significantly associated with the occurrence of RH, even after adjusting for variables associated with RH in univariate logistic regression analysis (age and body mass index) as well as the average daily calorie intake (odds ratio, 5.37; 95% confidence interval, 1.60-18.1; p = .0066). We identified that diets with higher carbohydrate contents were associated with RH in inpatients with AN, even after adjusting for known risk factors. Our findings may promote the development of dietary preventive strategies against RH in inpatients with AN.

Refeeding hypophosphataemia in patients on parenteral nutrition: Prevalence, risk factors and predicting its occurrence

Rationale: Patients on parenteral nutrition (PN) may develop refeeding hypophosphataemia (RH) and manifest clinical complications. To assess RH, several diagnostic criteria are used which may account to the highly variable prevalence in the literature (15–62%)1. To identify at-risk patients, the National Institute for Health and Clinical Excellence (NICE) guidelines is used widely but lacks validation. We aim to: 1) determine if the prevalence of RH is influenced by different diagnostic criteria; 2) validate the prognostic accuracy of the NICE guidelines in predicting RH; and 3) identify important risk factors for a new model to better predict RH.

Refeeding Hypophosphatemia in Patients Receiving Parenteral Nutrition: Prevalence, Risk Factors, and Predicting Its Occurrence.

Patients receiving parenteral nutrition (PN) support may develop refeeding hypophosphatemia (RH), and its prevalence is highly variable in the literature. Identifying at-risk patients is crucial to minimize clinical complications. The National Institute for Health and Clinical Excellence (NICE) guidelines are used widely to assess the risk of RH, but they lack validation. We aim to (1) identify the prevalence of RH by multiple diagnostic criteria; (2) assess the predictive ability of the NICE guidelines for RH; and (3) identify important risk factors for RH and evaluate their predictive abilities for RH in a new model. This is a single-center retrospective study on adult patients with PN ≥48 hours. Prevalence of RH was determined by 4 established diagnostic criteria. Prognostic accuracy of the NICE guidelines were assessed by the area under the receiver operating characteristic (ROC) curve. Multivariable logistic regressions were performed to develop a new risk-assessment model. Of 149 enrolled patients, 23%-48% (35 to 72 of 149 patients) developed RH (depending on the diagnostic criteria used). The NICE guidelines demonstrated poor discrimination across all diagnostic criteria (ROC, 0.43-0.53). Critical illness, the use of diuretics, and hypomagnesemia prior to PN were independently associated with RH. These risk factors formed the new model for predicting RH and had good discrimination (ROC 0.74; 95% confidence interval, 0.66-0.82). Prevalence of RH varied according to established diagnostic criteria. The current NICE guidelines poorly predict the occurrence of RH, and modification is likely beneficial. A new risk-assessment model was developed; nevertheless, further validation is required.

Extreme anorexia nervosa: medical findings, outcomes, and inferences from a retrospective cohort

BackgroundExtreme anorexia nervosa (AN) is defined as a BMI < 15 kg/m2 in those meeting DSM-V diagnostic criteria for AN. This study seeks to define the frequency of medical complications in this group of patients in order to help inform the care of individuals < 65% ideal body weight who seek treatment for their extreme eating disorders.MethodsThrough retrospective chart review and computerized data collection, we obtained the baseline characteristics and medical findings of 281 adult patients, with AN restricting and binge-purge subtypes, admitted to the ACUTE unit for medical stabilization between May 2013 and August 2018.ResultsIn this population, with a mean admitting BMI of 12.1 kg/m2 (range = 7.5–15.7), 56% admitted with bradycardia, 45% demonstrated increased liver function tests (LFTs) on admission, 64% admitted with leukopenia, 47% with anemia, and 20% presented with thrombocytopenia. During admission, 38% developed hypoglycemia, 35% developed refeeding hypophosphatemia, nearly 33% of patients developed edema, and low bone mineral density was diagnosed in almost 90% of the patients. Highly elevated LFTs (>3x upper limits of normal) predicted hypoglycemia, and low BMI predicted refeeding hypophosphatemia (p = .001).ConclusionsAlthough conclusions drawn from the findings presented in this descriptive study must be tempered by relevant clinical judgement, these findings showcase that patients with extreme AN are at significantly increased risk for many serious medical complications secondary to their state of malnutrition and also with initial refeeding.

Body mass index cut-off point associated with refeeding hypophosphatemia in adults with eating disorders.

Refeeding hypophosphatemia (RH) is a life-threatening complication in underweight patients with eating disorders (EDs). Although a lower body mass index (BMI) has been reported as a risk factor for RH, the exact BMI cut-off point is not known. Herein, we aimed to identify the optimal BMI cut-off point for RH in adults with EDs. The medical charts of Japanese inpatients with EDs at our hospital between April 1, 2012 and March 31, 2017 were retrospectively reviewed. The optimal BMI cut-off point for RH was determined via receiver operating characteristic analysis. Logistic regression analysis was subsequently performed to assess the association between RH and the BMI cut-off point after adjusting for the propensity score, which was based on known risk factors for RH. The optimal BMI cut-off point was identified as 12.6 kg/m2 . A BMI lower than the cut-off point significantly correlated with the occurrence of RH after adjusting for the propensity score. The optimal BMI cut-off point for the occurrence of RH was 12.6 kg/m2 in adults with EDs. The findings of the present study may facilitate clinical decision making and early identification of patients who require prophylactic treatment for RH.