LAUSR

We read with interest the study authored by Dr. Matthews et al. [1] questioning whether or not refeeding syndrome (RFS) actually leads to death because in their retrospective analysis, RFS was not well associated with deaths according to the medical charts. Although we agree with the conclusion that detailed research is warranted to assist in the identification of those distinctly at risk of RFS, we would caution interpretation of their clinical data. Obviously, a physician will only include RFS into his notes and medical charts if he recognizes this syndrome and does not misinterpret low phosphate levels as part of the general patient sickness. Thus, absence of medical chart information regarding RFS in nonsurvivors does not mean that these patients did not suffer from RFS, but rather that RFS was not diagnosed. There are several arguments in favor of RFS being an important and potentially lethal complication of nutritional therapy in patients at risk. First, we have several reports from prisoners liberated from concentration camps in World War II [2, 3] showing higher mortality than expected after start of nutritional therapy. Second, we recently completed a comprehensive meta-analysis on the subject matter and found a large number of studies describing RFS cases and also associated morbidity and mortality [4]. Owing to the uncertainties in diagnosis and treatment, we believe that the true number of affected causes might be significantly higher than previously reported. Third, there is a recent randomized trial proving that protocolized caloric restriction is a suitable therapeutic option for critically ill adults who develop RFS with an improvement in mortality [5]. Although there is work to do in regard to RFS and remaining uncertainty, we recommend that upon hospital admission, the use of specific screening criteria for risk assessment regarding the occurrence of RFS should be used [6, 7]. According to the individual risk of a patient for RFS, a careful start of nutritional therapy with a step-wise increase in energy and fluids goals, supplementation of electrolyte and vitamins, and a close clinical monitoring is recommended. In case of imminent or manifest RFS, there should be an adaption of the nutritional therapy. The absence of evidence reported by Dr. Matthews and colleagues [8] should not mislead us to be less careful about this syndrome, or about nutritional support in patients benefitting from such therapies [9].