World J Oncol

World Journal of Oncology, ISSN 1920-4531 print, 1920-454X online, Open Access

Article copyright, the authors; Journal compilation copyright, World J Oncol and Elmer Press Inc

Journal website http://www.wjon.org

Case Report

Volume 8, Number 1, February 2017, pages 25-29

Refeeding Syndrome in Oncology: Report of Four Cases

Figure 1. Courses of individual serum phosphate levels. The red diamond depicts the start of nutrition.

**Table 1.** Laboratory Findings of Four Consecutive Patients With the Refeeding Syndrome
	Patient 1	Patient 2	Patient 3	Patient 4
A: admission; B: start of nutritional support; C: phosphate nadir; D: last lab result before discharge. Numbers denote hospital day.
Na⁺ (mmol/L)	137	142	141	143	136	127	128	129	139	129	127	134	151	157	136	140
K⁺ (mmol/L)	3.7	3.1	3.7	3.7	4.6	3.7	3.4	3.6	3.7	3.0	3.5	3.7	2.9	2.7	3.2	3.1
Ca²⁺ (mmol/L)	2.47	2.08	2.04	2.33	2.35	2.00	1.75	1.64	2.40	2.13	2.00	2.30	2.63	1.99	2.06	1.83
Mg²⁺ (mmol/L)	0.75	0.67	0.71	0.84	0.59	0.58	0.37	0.40	0.75	0.69	0.54	0.66	0.81	0.65	0.45	0.63
Cl^- (mmol/L)	99	110	110	108	101	94	94	98	1.22	90	92	96	116	127	107	107
PO₄^3- (mmol/L)	0.88	0.65	0.15	1.05	0.97	0.56	0.27	0.61	0.76	0.73	0.27	0.68	0.94	0.14	0.24	0.63

Table 1. Laboratory Findings of Four Consecutive Patients With the Refeeding Syndrome

Patient 1

Patient 2

Patient 3

Patient 4

D13

B13

C19

D22

C10

D15

D20

A: admission; B: start of nutritional support; C: phosphate nadir; D: last lab result before discharge. Numbers denote hospital day.

Na⁺ (mmol/L)

137

142

141

143

136

127

128

129

139

129

127

134

151

157

136

140

K⁺ (mmol/L)

3.7

3.1

3.7

4.6

3.7

3.4

3.6

3.7

3.0

3.5

3.7

2.9

2.7

3.2

3.1

Ca²⁺ (mmol/L)

2.47

2.08

2.04

2.33

2.35

2.00

1.75

1.64

2.40

2.13

2.00

2.30

2.63

1.99

2.06

1.83

Mg²⁺ (mmol/L)

0.75

0.67

0.71

0.84

0.59

0.58

0.37

0.40

0.75

0.69

0.54

0.66

0.81

0.65

0.45

0.63

Cl^- (mmol/L)

110

108

101

1.22

116

127

107

PO₄^3- (mmol/L)

0.88

0.65

0.15

1.05

0.97

0.56

0.27

0.61

0.76

0.73

0.27

0.68

0.94

0.14

0.24

0.63

**Table 2.** Guideline for the Management of the RFS (Adapted From Refs. [5, 21, 22])
For detailed recommendations regarding electrolyte substitution, see particularly Ref. [22].
Identify patients at risk (“Discussion”)
Check electrolytes prior to re-alimentation and correct deficiencies
Administer thiamine 200 - 300 mg daily
Limit salt and fluid intake
Start feeding 10 kcal/kg/day and slowly increase over the first week
Monitor electrolytes and weight daily
If severe hypophosphatemia (< 0.3 mmol/L) develops: give phosphate parenterally*
*Assuming normal renal function, parenteral phosphate repletion is generally safe with doses up to 45 mmol with infusion rates up to 20 mmol per hour. Individualized frequent checks are recommended (e.g. after 6 and 12 h on day 1) [25].

Table 2. Guideline for the Management of the RFS (Adapted From Refs. [5, 21, 22])

For detailed recommendations regarding electrolyte substitution, see particularly Ref. [22].

Identify patients at risk (“Discussion”)

Check electrolytes prior to re-alimentation and correct deficiencies

Administer thiamine 200 - 300 mg daily

Limit salt and fluid intake

Start feeding 10 kcal/kg/day and slowly increase over the first week

Monitor electrolytes and weight daily

If severe hypophosphatemia (< 0.3 mmol/L) develops: give phosphate parenterally*

*Assuming normal renal function, parenteral phosphate repletion is generally safe with doses up to 45 mmol with infusion rates up to 20 mmol per hour. Individualized frequent checks are recommended (e.g. after 6 and 12 h on day 1) [25].

**Table 3.** NICE Criteria for Identifying Patients at High Risk of Refeeding Problems (Adapted From [21])
	1	2	3	4
Numbers 1 - 4: individual patients. +/- denotes presence/absence of a risk factor. n/a: not available.
One or more of the following:
BMI < 16 kg/m²	-	-	-	-
Weight loss > 15% within the last 3 - 6 months	n/a	+	-	+
Little or no nutritional intake for more than 10 days	+	-	-	-
Low levels of electrolytes prior to feeding	+	+	+	+
Two or more of the following:
BMI < 18.5 kg/m²	+	+	-	-
Weight loss > 10% within the last 3 - 6 months	n/a	+	+	+
Little or no nutritional intake for more than 5 days	+	+	+	+
History of alcohol abuse or drugs including chemotherapy	-	+	+	+

Table 3. NICE Criteria for Identifying Patients at High Risk of Refeeding Problems (Adapted From [21])

Numbers 1 - 4: individual patients. +/- denotes presence/absence of a risk factor. n/a: not available.

One or more of the following:

BMI < 16 kg/m²

Weight loss > 15% within the last 3 - 6 months

n/a

Little or no nutritional intake for more than 10 days

Low levels of electrolytes prior to feeding

Two or more of the following:

BMI < 18.5 kg/m²

Weight loss > 10% within the last 3 - 6 months

n/a

Little or no nutritional intake for more than 5 days

History of alcohol abuse or drugs including chemotherapy