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Association of early parenteral energy provision with serum phosphorus decline and phosphorus-based refeeding syndrome in critically ill patients with liver cirrhosis: a Korean retrospective observational study
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Jee Young Lee
 , Yeo Kon Kye, Kwang Il Seo, Kyung Won Seo, SooYong Lee, Jesang Yu
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Received May 7, 2026 Accepted June 30, 2026 Published online July 16, 2026
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DOI: https://doi.org/10.15747/ACNM.26.0055
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 Abstract
- Background
Critically ill patients with liver cirrhosis are vulnerable to malnutrition and refeeding-related electrolyte disturbances, particularly when total parenteral nutrition is initiated with rapid caloric advancement. Because hypophosphatemia is a key biochemical feature of refeeding syndrome (RFS), and because phosphorus homeostasis may be impaired in cirrhosis, we evaluated the association of early parenteral energy provision with serum phosphorus changes, phosphorus-based RFS occurrence, and RFS severity in patients with cirrhosis admitted to the intensive care unit (ICU).
Methods
This retrospective observational study included 72 adults with liver cirrhosis who were admitted to the ICU of a tertiary referral hospital between January 2021 and August 2024. Parenteral energy intake was assessed on the day of emergency department (ED) presentation, ICU day 1, and ICU day 2. Serum phosphorus reduction was defined as the percentage decrease from the baseline value at ED presentation to the nadir within the first 5 ICU days. For this study, RFS was operationally defined using the serum phosphorus component of the 2020 American Society for Parenteral and Enteral Nutrition consensus recommendations: a ≥10% decrease in serum phosphorus within 5 days after reinitiating or substantially increasing energy provision was classified as phosphorus-based RFS, with severity categorized as mild (10%–20%), moderate (20%–30%), or severe (>30%). Potassium and magnesium were not used as independent diagnostic criteria because serial measurements were not consistently available for all patients. Renal replacement therapy, diuretic use, and phosphate supplementation were reviewed because these concurrent ICU interventions may directly affect serum phosphorus concentrations.
Results
A total of 72 critically ill patients with liver cirrhosis who were admitted to the ICU via the ED were analyzed; 53 patients (73.6%) met the phosphorus-based RFS criterion. These included eight patients (11.1%) with mild, 10 (13.9%) with moderate, and 35 (48.6%) with severe phosphorus-based RFS, categorized according to the magnitude of serum phosphorus decline. ICU day 2 caloric intake per body weight was positively correlated with the percentage reduction in serum phosphorus (r=0.346, R²=0.120, P=0.003). In multivariable linear regression analysis, both ED glucose load and ICU day 2 caloric intake per body weight were independently associated with greater serum phosphorus reduction (P=0.001 and P=0.011, respectively). Only ICU day 2 caloric intake per body weight remained independently associated with meeting the phosphorus-based RFS criterion (odds ratio, 1.19; 95% confidence interval, 1.06–1.36; P=0.007). Receiver operating characteristic curve analysis demonstrated fair but modest discriminative performance for ICU day 2 caloric intake per body weight in identifying phosphorus-based RFS status, with an area under the curve of 0.7061 and an exploratory cutoff of 10.92 kcal/kg/day.
Conclusion
In critically ill patients with liver cirrhosis, higher caloric delivery on ICU day 2 was associated with greater serum phosphorus decline and a higher likelihood of meeting the phosphorus-based RFS criterion within this cohort. These findings should be interpreted as exploratory associations rather than evidence of a causal effect of nutritional support on RFS development. The proposed ICU day 2 cutoff should be considered a hypothesis-generating observation requiring external validation. Careful monitoring of caloric delivery and serial electrolytes, including phosphate, potassium, and magnesium, may support safer parenteral nutrition in this population.
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