Incidence and clinical predictors of refeeding syndrome among malnourished patients in a tertiary care hospital

A Prospective, Analytical Single Center Study

Abstract

Introduction: Malnutrition is highly prevalent among hospitalized patients and is a known significant risk factor for the development of Refeeding Syndrome (RFS). However, data on the actual incidence and specific clinical predictors of RFS in the Philippines remain scarce. This study aims to determine the incidence of RFS and identify significant clinical predictors of its occurrence in a local tertiary hospital.

Methodology: This prospective, analytical single-center study was conducted at Vicente Sotto Memorial Medical Center (VSMMC) in Cebu City, Philippines, from October 2022 to December 2023. A total of 217 adult patients were screened for malnutrition risk using the Nutrition Risk Screening 2002 (NRS-2002) tool through bedside interview. RFS was defined according to the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria, based on NRS >4 and documented electrolyte changes (hypophosphatemia, hypokalemia, or hypomagnesemia) within five days post-resumption of feeding. Electrolyte levels, daily caloric intake, and protein intake were monitored. Significant risk factors were analyzed using binary logistic regression to ascertain the effect size and predictive utility.

Results: Of the 217 patients screened, 70 (32%) were categorized as high risk for malnutrition and RFS with an NRS 2002 score of at least 4. RFS occurred in 14 patients (20% of the at-risk cohort). Patients with RFS were significantly older (mean age 54.71 + 18.20; p=0.44) and demonstrated significantly lower mean daily total protein intake (41.25 + 12.88 g/day; p=0.01) and lower mean total caloric intake (884.64 + 559.25 kcal/day; p=0.01) compared to the non-RFS group. Serum albumin (2.59 + 0.27 g/dL; p=0.035), phosphorus (1.66 + 0.29 mg/dL; p=0.00), magnesium (1.96 + 0.36 mg/dL; p=0.04) and potassium (3.13 + 0.43 meq/L; p=0.002) were likewise lower among the RFS group. Higher incidence of arrhythmia (50% vs 21%; p=0.003), shock (64% vs 32%; p=0.027), ventilatory support (71% vs 23%; p=0.01) and mortality (64.29% vs 21.43%; p=0.003) were noted in subjects who developed RFS. Binary logistic regression identified advanced age (NRS component) and total protein intake <50g/day as the strongest independent predictors of RFS occurrence.

Conclusion and Recommendations: The incidence of RFS (20%) among at-risk patients in this tertiary care setting was high, indicating that RFS represented a significant cause of in-hospital morbidity and mortality. Advanced age and total protein intake less than 50g/day were identified as crucial, independent predictors. These findings enforced the consistent, mandatory implementation of nutritional risk screening for all admitted patients, especially the elderly, and immediate referral to the Clinical Nutrition Service to ensure rapid, prophylactic, and safely titrated nutritional support.

Keywords: Refeeding Syndrome, Malnutrition, Hypophosphatemia