Annals of Clinical Nutrition and Metabolism

Original Articles

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: Jee Young Lee, Yeo Kon Kye, Kwang Il Seo, Kyung Won Seo, Sooyong Lee, Jesang Yu; Ann Clin Nutr Metab 2026;18(2):162-172. Published online July 31, 2026; DOI: https://doi.org/10.15747/ACNM.26.0055

Graphical Abstract Abstract PDF: Purpose
Critically ill patients with liver cirrhosis are vulnerable to malnutrition and refeeding-related electrolyte disturbances, particularly with rapid caloric advancement. As hypophosphatemia is a key feature of refeeding syndrome (RFS) and phosphorus homeostasis may be impaired in cirrhosis, the association of early parenteral energy provision with serum phosphorus decline and RFS was evaluated in cirrhotic ICU patients.
Methods
This retrospective study included 72 adults with liver cirrhosis admitted to a tertiary intensive care unit (ICU) between January 2021 and August 2024. Parenteral energy intake was assessed at emergency department (ED) and on ICU days 1 and 2. Serum phosphorus reduction was defined as the percentage decrease from baseline to the nadir within 5 ICU days. Phosphorus-based RFS was defined per the 2020 ASPEN consensus as a ≥10% phosphorus decrease after reinitiating or increasing energy provision, graded as mild, moderate, or severe.
Results
Phosphorus-based RFS occurred in 53 patients (73.6%), including severe RFS in 35 (48.6%). ICU day 2 caloric intake per body weight correlated with phosphorus reduction (r=0.346, P=0.003) and was independently associated with greater decline (P=0.011) and with meeting RFS criteria (odds ratio, 1.19; 95% CI, 1.06–1.36; P=0.007), along with ED glucose load (P=0.001). ROC analysis showed modest discrimination (AUC 0.7061; cutoff, 10.92 kcal/kg/day).
Conclusion
Higher caloric delivery on ICU day 2 was associated with greater phosphorus decline and RFS in cirrhotic ICU patients. These exploratory associations do not establish causality, and the cutoff requires external validation. Monitoring caloric delivery and serial electrolytes may support safer parenteral nutrition.

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Refeeding Syndrome in Critically Ill Patients: Sang Woo Ha, Suk-Kyung Hong; Ann Clin Nutr Metab 2022;14(2):72-80. Published online December 1, 2022; DOI: https://doi.org/10.15747/ACNM.2022.14.2.72

Purpose: The aim of this study is to demonstrate clinical characteristics of refeeding syndrome (RS) and clinical utility of several guidelines including American Society for Parenteral and Enteral Nutrition consensus recommendations for RS and National Institute for Clinical Excellence guidelines.
Materials and Methods: Eighty-six patients screened for RS based on two guidelines were enrolled in this study. We evaluated the severity of RS after the initiation of ‘dextrose infusion’ and ‘balanced nutrition support’ with calculation of 5-day electrolyte changes. The primary outcome was 6-month mortality and secondary outcomes were duration of intensive care unit stay in days, duration of mechanical ventilation in days, and ventilator-free days at the 28th day.
Results: We observed statistically different distributions in terms of prevalence of RS on the basis of two different start times of caloric support (P=0.021). There was no statistically significant relationship between the risk of RS and severity of RS based on both guidelines. Also, the relevance between severity of RS and outcomes was not significant in our study. In multivariable logistic regression analysis of factors associated with outcomes, the significant factor for primary outcome was the ‘patients with significant risk’ (odds ratio, 9.65; 95% confidence interval, 1.83~50.90; P=0.007).
Conclusion: We demonstrated that even initial administration of dextrose solution and propofol could cause severe RS in critically ill patients. In addition, significant risk of RS was a predictive factor for 6-month mortality. Thus, it is essential to monitor the occurrence of RS even during initial resuscitation in patients with unstable metabolism.

Citations

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Recent advances in refeeding syndrome in critically ill patients: a narrative review
Sang Woo Ha, Suk-Kyung Hong
Annals of Clinical Nutrition and Metabolism.2024; 16(1): 3. CrossRef

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