Acute Ischemic Stroke Patients and Risk of Refeeding Syndrome

Susan Kreimer for Medscape

February 15, 2022

The study covered in this summary was published in as a preprint and has not yet been peer reviewed.

Key Takeaways

  • Patients with acute ischemic stroke (AIS) have a greater likelihood of developing refeeding syndrome (RFS) — fluid and electrolyte disturbances during refeeding after a long period of malnutrition.

  • RFS occurs as a result of the elevated need for nutritional support when suffering dysfunction of consciousness and deglutition after stroke.

  • This study attempts to assess the occurrence, risk factors, and outcomes of RFS in AIS patients.

Why This Matters

  • RFS can lead to failure of various bodily systems: respiratory, cardiac, hepatic, hematologic, and neurologic. It also can cause death.

  • Either enteral or parenteral nutritional support can induce RFS.

  • Malnutrition is common in AIS patients. These patients need nutritional support due to dysfunction of deglutition, cognitive, and consciousness as well as heightened metabolic needs. Therefore, AIS patients may have a higher propensity to develop RFS.

  • Reports indicate that RFS is significantly associated with poor prognosis by raising the risk of mortality and continuing disability, so it is of considerable importance to identify high-risk patients of RFS and embark on strict nutritional management for AIS patients.

  • The main physiologic characteristic of RFS is hypophosphatemia, and diagnostic criteria for RFS were commonly defined as new onset of hypophosphatemia with a fall of phosphate levels >0.16 mmol/L to below 0.65 mmol/L.

Study Design

  • The researchers retrospectively reviewed consecutive patients diagnosed with AIS requiring enteral or parental nutritional support who were admitted to the stroke unit of Guangdong Hospital of Traditional Chinese and Western Medicine between January 1, 2019, and December 31, 2021.

  • To be included in the study, patients had to meet the following criteria: (1) acute ischemic stroke demonstrated by diffusion-weighted imaging; (2) intracranial hemorrhage (ICH) excluded by noncontrast CT; (3) receiving enteral or parental nutritional support for >72 hours; (4) serum phosphate records before refeeding and at 72 ± 12 h after refeeding.

  • The study excluded patients if they met any the following criteria: (1) incomplete data on nutrition provision; (2) aged >85 or <18 years; (3) serum phosphate <0.65 mmol/L at admission; (4) lost to follow-up; (5) end-stage malignant diseases; (6) complications for diabetic ketoacidosis; or (7) recent parathyroidectomy or receiving renal replacement therapy, using phosphate binders, or undergoing the therapeutic hypothermia.

  • Informed consent from patients or review board was waived, owing to the study's observational and retrospective characteristics.

Key Results

  • Of the 1038 patients included in the study, 154 patients (14.8 %) developed RFS. In this cohort, 684 patients were male (65.9%), and the average age was 64 years.

  • Risk factors for RFS in AIS patients were baseline National Institutes of Health Stroke Scale (NIHSS), nutritional risk screening 2002, albumin <30 g/L, and body mass index <18.5 kg/m2.

  • Patients in the RFS group had lower promotion of 7-day NIHSS; RFS was independently associated with a 3-month mRS score of >2 as well as 6-month mortality.

  • Hypophosphatemia may lead to worse stroke outcomes, and it may directly induce secondary neuromuscular injury or exacerbate neurologic ischemia by reducing oxygen delivery of red blood cells. Moreover, hypophosphatemia would result in respiratory muscle dysfunction and potentially could lead to respiratory failure.

  • Continuous neurologic disability and higher risk of death ultimately occur due to all these pathologic changes.


  • This is a retrospective, single-center study that excluded those lost to follow-up or without serum phosphate at 72 hours. However, the resulting selection bias and residual confounding may be partly compensated by the prospectively collected database.

  • Some patients who may have developed RFS after 72 hours were counted in the non-RFS group, which may underestimate the incidence of RFS.

  • Due to the small number of RFS patients, the authors did not perform multi-subgroup analysis on diverse stroke severity and stroke subtypes to add clarity to the prevalence and risk factors of RFS in AIS patients.

  • A prospective, randomized cohort study would be necessary to confirm the findings.

Study Disclosures

  • The authors have disclosed no relevant financial relationships.

This is a summary of a preprint research study, "Risk Factors and Outcomes for Refeeding Syndrome in Acute Ischemic Stroke Patients," written by Shumin Chen from Guangdong Hospital of Integrated Traditional Chinese and Western Medicine, affiliated hospital of Traditional Chinese University of Guangzhou, on medRxiv provided to you by Medscape. This study has not yet been peer reviewed. The full text of the study can be found on

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