Fluid and electrolyte disturbances are a challenging problem of inpatients, especially in those subpopulations, in whom the electrolyte imbalance is involved in the pathogenesis of the primary disease. Here we present the case of a 58 year old woman, with ongoing alcohol abuse on a daily basis, who was admitted with progressive fatigue and dysphagia. At the admission BMI was 17.8 kg/m2, and the patient presented deficiency of vitamins A, B, and D. The diagnostic procedures did not reveal the cause of dysphagia, which was therefore considered to be a functional disorder. We started parenteral nutrition to provide sufficient calories and intravenous substitution of vitamins. Despite clinical improvement we were confronted with a gradual decompensation of electrolytes, i.e. marked hypokalemia, hypocalcemia, hypomagnesemia, and hypophosphatemia. The electrolyte deficiencies were refractory to intermittent intravenous substitution and required continuous administration via perfusor with very rapid relapse after discontinuation. Acute or chronic kidney injury could not be proven. Hyperaldosteronism and hypercortisolemia were also excluded. The existence of a genetic disorder affecting the electrolyte balance was considered unlikely because of the absence of similar findings at younger age and no affected family members. Taken together we considered the electrolyte decompensation to be caused by refeeding syndrome. Refeeding syndrome is a well described but often underestimated condition that reflects hormonal and metabolic changes in a malnourished patient after initiation of iso- or hypercaloric nutrition and reflects the adaptation of intracellular electrolytes in the anabolic state. Given that many electrolyte disturbances can be asymptomatic, refeeding syndrome needs close monitoring of fluid and electrolyte fluctuations, especially in at-risk patients. Under rigorous monitoring, we could stepwise reduce the continuous substitution of potassium and phosphate and the need for magnesium. At the time of discharge, the patient achieved a BMI of 18.5 kg/m2, reported substantial improvement of the dysphagia and no need for oral intake of electrolyte supplements.
18 - 21 May 2019
European Society of Endocrinology