Factors contributing to the development of hypophosphataemia when refeeding using parenteral nutrition
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Aim To identify individual attributes or risk factors which predispose to the development of refeeding hypophosphataemia in patients on parenteral nutrition (PN). Setting The Royal Surrey County Hospital (RSCH) a 530 bed, non-teaching Trust with a cancer centre, medical and surgical inpatients and intensive care unit (ICU). Subjects were recruited prospectively from all adult inpatients referred for initiation of PN. Method Seventy patients (cases) with refeeding hypophosphataemia were matched with controls who had not experienced a fall in phosphate levels when commenced on PN. Their nutritional requirements, nutrition intake, and biochemical test results were compared and statistical analyses performed to show if any differences between cases and controls were due to chance. Results Independent risk factors for developing refeeding hypophosphataemia were: significant malnutrition measured as a Nutrition Risk Screening (NRS) score of three or more; less than 12 mmols total phosphate in the first day’s PN regimen; and an initial rate of infusion of PN of more than 70% of calculated requirements. In addition increasing amounts of non-lipid phosphate in the first day’s PN regimen were found to be protective. Hypomagnesaemia prior to starting PN was non-significantly associated with refeeding hypophosphataemia. Other biochemical markers included in the study: albumin, calcium, C-reactive protein, glucose and urea, did not show an association. ICU, cancer and postoperative patients were not found to be more at risk. Conclusion Patients with a high NRS score prior to commencing nutrition support may be more at risk than others of refeeding hypophosphataemia. The first 24 h PN regimen should be run slowly providing less than 70% of calculated protein and calorie requirements but containing more than 12 mmol phosphate.
KeywordsCase control study Hypophosphatemia Parenteral nutrition Refeeding Risk factors United Kingdom
The authors wish to acknowledge the input by other members of the RSCH Trust Nutrition Support Team and the support of the pharmacy department staff.
No financial support was received. No conflict of interests to declare.
- 5.Gonzalez A, Fajardo R, Gonzalez F. The incidence of the refeeding syndrome in cancer patients who receive artificial nutritional treatment. Nutr Hosp. 1996;11(2):98–101.Google Scholar
- 7.Meyler’s side effects of drugs. 14th ed. Oxford: Elsevier; 2000.Google Scholar
- 8.Electronic Medicines Compendium.: Summary of Product Characteristics. Retrieved March 31st 2006, from http://emc.medicines.org.uk/; 2006.
- 9.Department of Health. Dietary reference values for food energy and nutrients for the United Kingdom: report of the panel on dietary reference values of the committee on medical aspects of food policy. London: HMSO; 1991. Report No.: Report No. 41.Google Scholar
- 10.Marvin V, May C, Livingstone C, Davis J. Incidence of hypophosphataemia in patients on parenteral nutrition. Hosp Pharm. 2007;14:166–9.Google Scholar
- 13.DeCock A, Mana F, Velkeniers B, Urbain D. Hypophosphataemia and refeeding: a corrective or preventive attitude? Acta Clin Belg. 2006;61(3):134–7.Google Scholar
- 15.Malnutrition Advisory Group. Malnutrition universal screening tool (MUST). Redditch: British Association for Parenteral and Enteral Nutrition (BAPEN); 2003.Google Scholar
- 17.National Institute for Health and Clinical Excellence (NICE) Nutrition suppport in adults. Oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline. London: National Health Service; 2006. Report No.: 32.Google Scholar
- 22.Walmsley RN, Watkinson LR, Cain HJ. Cases in chemical pathology: a diagnostic approach. 4th ed. Singapore: World Scientific Publishing Co.; 1999.Google Scholar
- 24.Stratton RJ, Green CJ, Elia M. Disease related malnutrition: an evidence based approach to treatment. Oxon: CABI Publishing; 2003.Google Scholar
- 26.White R. Peri-operative nutrition—the role of the pharmacist. Hosp Pharm. 2006;13(10):361–4.Google Scholar
- 28.Martindale. The extra pharmacopoeia. 34th ed. London: Pharmaceutical Press; 2005.Google Scholar
- 29.Institute of Medicine. Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D and fluoride. Retrieved October 18th 2005, from http://www.nap.edu/openbook/0309063507/html/146.html/; 2000.
- 30.Fresenius Kabi Limited. Kabiven®, Addiphos®: Summary of product characteristics. Warrington; 2000.Google Scholar
- 31.Mason P. Upper safety limits for vitamins - why have different authorities set different guidance? Pharm J. 2003;271:55–7.Google Scholar
- 34.Chaieb SD, Chaumeil JC, Jebnoun S, Khrouf N, Hedhili A, Sfar S. Calcium and phosphate compatibility and stability studies in different neonatal parenteral nutrition mixtures. Eur J Hosp Pharm Sci. 2006;12(2):35–40.Google Scholar
- 39.Brooks MJ, Melnik G. The refeeding syndrome: an approach to understanding its complications and preventing its occurrence. Pharmacother 1995;15(6):713–26.Google Scholar