Introduction
Methods
Incidence rates for RFS
Population at risk for RFS
Malnutrition [40] |
At least 1 phenotypic criterion and 1 etiologic criterion should be present Phenotypic Criteria: Nonvolitional weight loss Low body mass index Reduced muscle mass Etiologic criteria: Reduced food intake or assimilation Disease burden/inflammation condition |
Starvation [44] |
Reduction in both fat and fat-free mass due to protein–energy deficiency, which could be reversed solely by the provision of nutrients |
Cachexia [42] |
Severe weight loss (adults) or growth failure (children) due to loss of muscle ± loss of fat mass associated with increased protein catabolism by underlying chronic illness |
Cancer cachexia [41] |
A multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment |
Sarcopenia [43] |
Sarcopenia is a progressive and generalized skeletal muscle disorder that is associated with increased likelihood of adverse outcomes including falls, fractures, physical disability, and mortality. |
Sarcopenia is probable when low muscle strength is detected (handgrip strength < 27 kg for males and < 16 kg for females). A sarcopenia diagnosis is confirmed by the presence of low muscle quantity or quality (ASM/height2 < 7.0 kg/m2 for males and < 5.5 kg/m2 for females). When low muscle strength, low muscle quantity/quality and low physical performance (low gait speed ≤ 0.8 m/s both for males and females) are all detected, sarcopenia is considered severe |
NICE [48] | ASPEN 2020 [33] | Friedli 2018 [21] | |||||
---|---|---|---|---|---|---|---|
High risk in the presence of | Moderate risk: 2 risk criteria needed | Significant risk: 1 risk criteria needed | Low risk: 1 minor risk factor | High risk: 1 major or 2 minor risk factors | Very high risk | ||
One or more of the following: | Two or more of the following: | Minor risk factors | Major risk factors | ||||
BMI | < 16 kg/m2 | < 18.5 kg/m2 | 16–18.5 kg/m2 | < 16 kg/m2 | < 18.5 kg/m2 | < 16 kg/m2 | < 14 kg/m2 |
Weight loss | > 15% within the last 3–6 months | > 10% within the last 3–6 months | 5% in 1 month | 7.5% in 3 months or > 10% in 6 months | > 10% within the last 3–6 months | > 15% within the last 3–6 months | > 20% |
Caloric intake | Little or no nutritional intake > 10 days | Little or no nutritional intake > 5 days | None or negligible oral intake for 5–6 days OR < 75% of estimated energy requirement for > 7 days during an acute illness or injury OR < 75% of estimated energy requirement for > 1 month | None or negligible oral intake for > 7 days OR < 50% of estimated energy requirement for > 5 days during an acute illness or injury OR < 50% of estimated energy requirement for > 1 month | Little or no nutritional intake > 5 days | Little or no nutritional intake > 10 days | Starvation > 15 days |
Prefeeding potassium, phosphate, or magnesium serum concentrations | Low levels | Minimally low levels or normal current levels and recent low levels necessitating minimal or single‐dose supplementation | Moderately/significantly low levels or minimally low or normal levels and recent low levels necessitating significant or multiple‐dose supplementation | Low levels | |||
Loss of subcutaneous fat | Evidence of moderate loss | Evidence of severe loss | |||||
Loss of muscle mass | Evidence of mild or moderate loss | Evidence of severe loss | |||||
Higher‐risk comorbidities* | A history of alcohol abuse or drugs including insulin, chemotherapy, antacids, or diuretics | Moderate disease | Severe disease | A history of alcohol abuse or drugs including insulin, chemotherapy, antacids, or diuretics |
Diagnosis of RFS
Severity of RFS | Mild | Moderate | Severe |
---|---|---|---|
Serum electrolytes* | 10–20% less | 20–30% less | > 30% less and/or organ dysfunction** |
Timing | From hours up to 5 days after increasing the energy provision in an individual at risk |
Pathophysiology and clinical manifestations
Insulin and carbohydrate metabolism
Hypophosphatemia
Pathophysiological mechanisms | Clinical manifestations |
---|---|
Hypophosphatemia | |
Increased phosphate consumption due to enhanced production of phosphorylated intermediates for glycolysis, the Krebs cycle, and the electron transport chain to produce adenosine triphosphate and 2,3-diphosphoglycerate | Impaired cardiac and respiratory functions (i.e., tachycardia and tachypnea) |
Neurologic symptoms (i.e., confusion, somnolence, lethargy, coma, paresthesia, seizures) | |
Hematologic disorders (i.e., hemolysis, dysfunction of platelets and leukocytes, thrombocytopenia) | |
Hypoxia (due to impaired oxygen release from 2,3- diphosphoglycerate) | |
Muscular disorders (i.e., weakness, rhabdomyolysis, decreased cardiac contractility, myalgia) | |
Hypokalemia | |
Intracellular shift of potassium by insulin stimulation of the Na + /K + ATPase | Cardiac arrhythmias |
Impairment of potassium reuptake in the nephron (role of hypomagnesemia) | Neurologic symptoms (i.e., weakness, hyporeflexia, respiratory depression, and paralysis) due to impaired transmission of electrical impulses |
Hypomagnesemia | |
Not completely clear Intracellular shift of magnesium after carbohydrate feeding | Increased renal losses of potassium |
Cardiac arrhythmias (i.e., torsade de pointes, atrial fibrillation, ventricular arrhythmias) | |
Electrocardiograph changes (i.e., prolonged QT and PR, widened QRS) | |
Abdominal discomfort (i.e., anorexia, diarrhea, nausea, vomiting) | |
Neuromuscular symptoms (i.e., tremor, paraesthesia, tetany, seizures, irritability, confusion, weakness, ataxia) | |
Thiamine deficiency | |
Increased consumption of thiamine by glucose metabolism enzymes | Neurologic disorders or dry beriberi, Wernicke encephalopathy and Korsakoff’s syndrome (i.e., ataxia, disturbance of consciousness, oculomotor abnormalities, symptoms of acute peripheral neuropathy, coma) |
Cardiovascular disorders or wet beriberi (i.e., peripheral edema, heart failure) | |
Metabolic acidosis (due to glucose conversion to lactate) | |
Sodium and fluid retention | |
Renal sodium and fluid retention due to insulin antinatriuretic properties (after carbohydrate feeding) | Peripheral edema |
Pulmonary edema and heart failure (due to increased vasoconstriction and peripheral resistance by sodium stimulation of noradrenaline and angiotensin II) | |
Hyperglycemia | |
Increased tissue resistance to endogenous glucose | Metabolic acidosis |
Hypercapnia, respiratory failure, and risk of fatty liver due to lipogenesis (stimulated by insulin) |
Hypokalemia
Hypomagnesemia
Thiamine deficit
Prevention and treatment
Day | Treatment | Low risk | High risk | Very high risk | Monitoring |
---|---|---|---|---|---|
1 | Thiamine | 200–300 mg | 200–300 mg | 200–300 mg | Body weight Vital signs Clin Exam Lab tests§ |
Multivitamin* | Yes | Yes | Yes | ||
Sodium restriction | No | < 1 mmol/kg/day | < 1 mmol/kg/day | ||
Fluids | 30–35 ml/kg/day | 25–30 ml/kg/day | 20–25 ml/kg/day | ||
Nutritional support** | 15–25 kcal/kg/day | 10–15 kcal/kg/day | 5–10 kcal/kg/day | ||
2 | Thiamine | 200–300 mg | 200–300 mg | 200–300 mg | Body weight Vital signs Clin Exam Lab tests§ |
Multivitamin* | Yes | Yes | Yes | ||
Sodium restriction | No | < 1 mmol/kg/day | < 1 mmol/kg/day | ||
Fluids | 30–35 ml/kg/day | 25–30 ml/kg/day | 20–25 ml/kg/day | ||
Nutritional support** | 15–25 kcal/kg/day | 10–15 kcal/kg/day | 5–10 kcal/kg/day | ||
3 | Thiamine | 200–300 mg | 200–300 mg | 200–300 mg | Body weight Vital signs Clin Exam Lab tests§ |
Multivitamin* | Yes | Yes | Yes | ||
Sodium restriction | No | < 1 mmol/kg/day | < 1 mmol/kg/day | ||
Fluids | 30–35 ml/kg/day | 25–30 ml/kg/day | 20–25 ml/kg/day | ||
Nutritional support** | 15–25 kcal/kg/day | 10–15 kcal/kg/day | 5–10 kcal/kg/day | ||
4 | Thiamine | No | No | 200–300 mg | Vital signs Clin Exam |
Multivitamin* | Yes | Yes | Yes | ||
Sodium restriction | No | < 1 mmol/kg/day | < 1 mmol/kg/day | ||
Fluids | 30–35 ml/kg/day | 30–35 ml/kg/day | 25–30 ml/kg/day | ||
Nutritional support** | 30 kcal/kg/day | 15–25 kcal/kg/day | 10–20 kcal/kg/day | ||
5 | Thiamine | No | No | 200–300 mg | Body weight Vital signs Clin Exam Lab tests§ |
Multivitamin* | Yes | Yes | Yes | ||
Sodium restriction | No | < 1 mmol/kg/day | < 1 mmol/kg/day | ||
Fluids | 30–35 ml/kg/day | 30–35 ml/kg/day | 25–30 ml/kg/day | ||
Nutritional support** | full requirements | 15–25 kcal/kg/day | 10–20 kcal/kg/day | ||
6 | Multivitamin* | Yes | Yes | Yes | Vital signs Clin Exam |
Sodium restriction | No | < 1 mmol/kg/day | < 1 mmol/kg/day | ||
Fluids | 30–35 ml/kg/day | 30–35 ml/kg/day | 25–30 ml/kg/day | ||
Nutritional support** | full requirements | 25–30 kcal/kg/day | 10–20 kcal/kg/day | ||
7 | Multivitamin* | Yes | Yes | Yes | Vital signs Clin Exam |
Sodium restriction | No | < 1 mmol/kg/day | < 1 mmol/kg/day | ||
Fluids | 30–35 ml/kg/day | 30–35 ml/kg/day | 30–35 ml/kg/day | ||
Nutritional support** | full requirements | full requirements | 20–30 kcal/kg/day | ||
8 | Multivitamin* | Yes | Yes | Yes | Vital signs Clin Exam |
Sodium restriction | No | No | < 1 mmol/kg/day | ||
Fluids | 30–35 ml/kg/day | 30–35 ml/kg/day | 30–35 ml/kg/day | ||
Nutritional support** | full requirements | full requirements | 20–30 kcal/kg/day | ||
9 | Multivitamin* | Yes | Yes | Yes | Body weight Vital signs Clin Exam Lab tests§ |
Sodium restriction | No | No | < 1 mmol/kg/day | ||
Fluids | 30–35 ml/kg/day | 30–35 ml/kg/day | 30–35 ml/kg/day | ||
Nutritional support** | Full requirements | Full requirements | 20–30 kcal/kg/day | ||
10 | Multivitamin* | Yes | Yes | Yes | Vital signs Clin Exam |
Sodium restriction | No | No | < 1 mmol/kg/day | ||
Fluids | 30–35 ml/kg/day | 30–35 ml/kg/day | 30–35 ml/kg/day | ||
Nutritional support** | Full requirements | Full requirements | Full requirements |