In Reply

Discussion Refeeding Syndrome Diagnostic Challenges and the Potential of Clinical Decision Support Systems by Dr. med. Lara Heuft, Dr. rer. nat. Jenny Voigt, M. Ed. Lars Selig, Prof. Dr. med. Michael Stumvoll, Dr. med. Haiko Schlögl, Prof. Dr. med. MaHM Thorsten Kaiser in issue 7/2023

Other reports from medical colleagues presented a similar picture from deployment areas where extreme malnutrition prevailed, as did memories of returning prisoners of war as v. Kietzell described from South Sudan. The disease course/progression was partly severe and ended fatally. The pathophysiology of refeeding syndrome (RFS) is not understood even today.

v. Kietzell’s suggestion is particularly interesting because it is reminiscent of the principle of delayed onset of endogenous hormone production, as is known from adrenal failure. Hypoglycemia, hyperventilation, and hyperinsulinemia have already been described for RFS in adults (1, 2). Hypoglycemia has also been observed. Hyperinsulinemia, however, is understood to be the over-reaction to the reintroduction of glucose into the metabolism. As a result an intracellular inflow of phosphate and glucose develops, as does an intracellular inflow of potassium as a result of stimulation of Na+-K+-ATPase.

In view of this pathogenesis, hyperventilation symptoms are to be understood as the expression of a weakness in the respiratory muscles as triggered by hypophosphatemia. The current guidelines therefore do not recommend insulin therapy (2, 3).

Intravenously applied glucose solution can be titrated on the basis of the target values for kcal/kg body weight/day (as a rule, for adults this is 10–20 kcal/kg body weight/day) (3). For children, the American Society for Parenteral and Enteral Nutrition (ASPEN) recommends initially an introductory dose of 40–50% of the overall calorie target with an infusion rate of 4–6 mg/kg/min (3). The implementation of these recommendations on site, or a practical instruction for how to deal with at-risk patients under aggravated conditions require a separate article.

DOI: 10.3238/arztebl.m2023.0156

On behalf of the authors

Dr. med. Lara Heuft

Institut für Humangenetik

Universitätsklinikum Leipzig

Conflict of interest statement

Dr. Heuft was involved in the development of the CDSS, the clinical implementation of which is reported in this article.

Other research partners in this project publicly funded under the eHealthSax guideline No.: 100331796 include the Muldental Clinics in Grimma and Wurzen as well as Xantas AG. On completion of the project, the option exists to transform the CDSS into a product. All research partners have independent and autonomous access to the knowledge gained.

References

1. Friedli N, Odermatt J, Reber E, Schuetz P, Stanga Z: Refeeding syndrome: update and clinical advice for prevention, diagnosis and treatment. Curr Opin Gastroenterol 2020; 36: 136–40

2. Stanga Z, Brunner A, Leuenberger M, et al.: Nutrition in clinical practice—the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Eur J Clin Nutr 2008; 62: 687–94

3. da Silva JSV, Seres DS, Sabino K, et al.: ASPEN Consensus Recommendations for Refeeding Syndrome. Nutr Clin Pract 2020; 35: 178–95

4. Heuft L, Voigt J, Selig L, Stumvoll M, Schlögl H, Kaiser T: Refeeding syndrome—diagnostic challenges and the potential of clinical decision support systems. Dtsch Arztebl Int 2023; 120: 107–14