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a pattern of symptoms indicative of some disease
a complex of concurrent things; "every word has a syndrome of meanings"

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(疾患の徴候となる一群の)症徴候,症候群 / (事件・社会的状態などのパターンを示す)徴候形態

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/03/14 09:28:38」(JST)

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Refeeding syndrome is a syndrome consisting of metabolic disturbances that occur as a result of reinstitution of nutrition to patients who are starved or severely malnourished.^[1] The syndrome was first^[2] described after World War II in Americans who, held by the Japanese as prisoners of war, had become malnourished during captivity and who were then released to the care of United States personnel in the Philippines.^[3]

§Syndrome

Any individual who has had negligible nutrient intake for more than 5 consecutive days is at risk of refeeding syndrome. Refeeding syndrome usually occurs within four days of starting to feed. Patients can develop fluid and electrolyte disorders, especially hypophosphatemia, along with neurologic, pulmonary, cardiac, neuromuscular, and hematologic complications.

During prolonged fasting the body aims to conserve muscle and protein breakdown by switching to ketone bodies derived from fatty acids as the main energy source. The liver decreases its rate of gluconeogenesis thus conserving muscle and protein. Many intracellular minerals become severely depleted during this period, although serum levels remain normal. Importantly, insulin secretion is suppressed in this fasted state and glucagon secretion is increased.^[4]

During refeeding, insulin secretion resumes in response to increased blood sugar; resulting in increased glycogen, fat and protein synthesis. This process requires phosphates, magnesium and potassium which are already depleted and the stores rapidly become used up. Formation of phosphorylated carbohydrate compounds in the liver and skeletal muscle depletes intracellular ATP and 2,3-diphosphoglycerate in red blood cells, leading to cellular dysfunction and inadequate oxygen delivery to the body's organs. Refeeding increases the basal metabolic rate. Intracellular movement of electrolytes occurs along with a fall in the serum electrolytes, including phosphate, potassium and magnesium. Glucose, and levels of the B₁ vitamin thiamine may also fall. Cardiac arrhythmias are the most common cause of death from refeeding syndrome, with other significant risks including confusion, coma and convulsions and cardiac failure.

This syndrome can occur at the beginning of treatment for anorexia nervosa when patients have an increase in calorie intake and can be lethal.^[5] The shifting of electrolytes and fluid balance increases cardiac workload and heart rate. This can lead to acute heart failure. Oxygen consumption is also increased which strains the respiratory system and can make weaning from ventilation more difficult.

§Treatment

Refeeding syndrome can be fatal if not recognized and treated properly. An awareness of the condition and a high index of suspicion are required in order to make the diagnosis.^[6] Refeeding syndrome occurs most commonly in those who have lost weight rapidly. The electrolyte disturbances of the refeeding syndrome can occur within the first few days of refeeding, which can be undertaken through the oral or nasogastric routes. Close monitoring of blood biochemistry is therefore necessary in the early refeeding period. Milk is often the refeeding food of choice in this early period as it is naturally high in phosphate and easily tolerated by those who have been starved. If potassium, phosphate or magnesium are low then this should be corrected via the oral route, or if severe with parenteral treatment. Prescribing thiamine, vitamin B complex (strong) and a multivitamin and mineral is recommended. Biochemistry should be monitored regularly until it is stable. Energy intake should remain only 50-70% that of normally required for the first 3–5 days.

Patients who have been starved for some time often experience gastrointestinal disturbance during refeeding, in particular colicky abdominal pain, reflux symptoms, nausea and early satiety. To help manage this, patients are often prescribed pro-kinetic agents such as domperidone or metoclopramide, as well as acid suppressants such as omeprazole. This may be of particular importance in patients suffering from anorexia nervosa, who can find these symptoms particularly distressing.

§See also

Minnesota Starvation Experiment where some effects of refeeding were documented.

§References

^ Mehanna HM, Moledina J, Travis J (June 2008). "Refeeding syndrome: what it is, and how to prevent and treat it". BMJ 336 (7659): 1495–8. doi:10.1136/bmj.a301. PMC 2440847. PMID 18583681.
^ Schnitker MA, Mattman PE, Bliss TL. A clinical study of malnutrition in Japanese prisoners of war. Ann Intern Med 1951;35: 69-96 PMID 14847450
^ SCHNITKER MA, MATTMAN PE, BLISS TL (July 1951). "A clinical study of malnutrition in Japanese prisoners of war". Annals of Internal Medicine 35 (1): 69–96. doi:10.7326/0003-4819-35-1-69. PMID 14847450.
^ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/
^ Webb GJ et al., Complications of emergency refeeding in anorexia nervosa: case series and review. Acute Medicine 2011;10(2):69-76. http://www.ncbi.nlm.nih.gov/pubmed/22041604
^ Assiotisa A, Elenin, H. Implications of refeeding syndrome in posteropative total parenteral nutrition. Grand Rounds 10 63-66, 2010 http://www.grandrounds-e-med.com/articles/gr100013.htm

§Bibliography

Shils, M.E., Shike, M., Ross, A.C., Caballero, B. & Cousins, R.J. (2006). Modern nutrition in health and disease, 10th ed. Lippincott, Williams & Wilkins. Baltimore, MD.
Mahan, L.K. & Escott-Stump, S.E. (2004) Krause’s Food, Nutrition, & Diet Therapy, 11th ed. Saunders, Philadelphia, PA.
Hearing S (2004). "Refeeding syndrome: Is underdiagnosed and undertreated, but treatable". BMJ 328 (7445): 908–9. doi:10.1136/bmj.328.7445.908. PMC 390152. PMID 15087326.
Crook M, Hally V, Panteli J (2001). "The importance of the refeeding syndrome". Nutrition 17 (7–8): 632–7. doi:10.1016/S0899-9007(01)00542-1. PMID 11448586.
Lauts N (2005). "Management of the patient with refeeding syndrome". J Infus Nurs 28 (5): 337–42. doi:10.1097/00129804-200509000-00007. PMID 16205500.
Kraft M, Btaiche I, Sacks G (2005). "Review of the refeeding syndrome". Nutr Clin Pract 20 (6): 625–33. doi:10.1177/0115426505020006625. PMID 16306300.
National Institute for Clinical Excellence (2008). CG32 Nutrition support in adults: full guideline. http://guidance.nice.org.uk/CG32/Guidance/pdf/English

UpToDate Contents

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1. 成人および思春期における神経性食思不振症：再栄養症候群 anorexia nervosa in adults and adolescents the refeeding syndrome
2. 摂食障害：治療の概要 eating disorders overview of treatment
3. 重症患者における栄養補給：非経口的栄養 nutrition support in critically ill patients parenteral nutrition
4. 成人および思春期における神経性無食欲症：栄養改善（栄養サポート） anorexia nervosa in adults and adolescents nutritional rehabilitation nutritional support
5. 2歳未満の小児における成長障害（低栄養）：マネージメント failure to thrive undernutrition in children younger than two years management

English Journal

Melanocortin-3 receptor regulates the normal fasting response.

Renquist BJ, Murphy JG, Larson EA, Olsen D, Klein RF, Ellacott KL, Cone RD.SourceDepartment of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, TN 37232.
Proceedings of the National Academy of Sciences of the United States of America.Proc Natl Acad Sci U S A.2012 Jun 5;109(23):E1489-98. Epub 2012 May 9.
The melanocortin-3 receptor-deficient (MC3-R(-/-)) mouse exhibits mild obesity without hyperphagia or hypometabolism. MC3-R deletion is reported to increase adiposity, reduce lean mass and white adipose tissue inflammation, and increase sensitivity to salt-induced hypertension. We show here that the
PMID 22573815

Anorexia Nervosa and the Kidney.

Bouquegneau A, Dubois BE, Krzesinski JM, Delanaye P.SourceDepartment of Nephrology, Dialysis, Transplantation, University of Liège, CHU Sart Tilman, 4000 Liège, Belgium.
American journal of kidney diseases : the official journal of the National Kidney Foundation.Am J Kidney Dis.2012 May 18. [Epub ahead of print]
Anorexia nervosa is a common psychiatric disorder that disproportionately affects adolescents and young adults and is associated with high rates of morbidity and mortality. Anorexia nervosa can affect the kidney in numerous ways, including increased rates of acute kidney injury and chronic kidney di
PMID 22609034

Japanese Journal

飢餓時の代謝とRefeeding Syndrome (特集代謝・栄養障害)

篠崎広一郎,平澤博之
救急医療ジャーナル 19(3), 50-55, 2011-06
NAID 40018878459

再栄養症候群 (Refeeding syndrome) により低リン血症を呈した症例での臨床的・文献的検討

木暮香織,川村光信,宮崎滋
日本病態栄養学会誌 13(3), 227-232, 2010-09-21
NAID 10027737399

敗血症の治療中に低リン血症を呈した神経性食思不振症の2例

島田忠長,織田成人,貞広智仁,仲村将高,安部隆三,奥怜子,篠崎広一郎,平澤博之
日本集中治療医学会雑誌 = Journal of the Japanese Society of Intensive Care Medicine 17(2), 197-202, 2010-04-01
NAID 10026278542

Related Pictures

★リンクテーブル★

リンク元	「代謝性アルカローシス」「低リン血症」「リフィーディング症候群」
関連記事	「syndrome」

「代謝性アルカローシス」

Refeeding syndrome
Classification and external resources
DiseasesDB	11205

　　[★]

英: metabolic alkalosis
関: アルカローシス、酸塩基平衡異常

酸塩基平衡異常とその代償 SP.660

	HCO3-	pCO2
呼吸性アシドーシス	↑	↑
呼吸性アルカローシス	↓	↓
代謝性アシドーシス	↓	↑
代謝性アルカローシス	↑	↓

原因

低カリウム性代謝性アルカローシス：H+とCl-の喪失：嘔吐、利尿薬など

嘔吐

細胞内からH+が供給され、K+が細胞内に移動しカリウムが低下する。H+の減少は遠位尿細管におけるHCO3-の排泄を抑制し代謝性アシドーシスが完成する。
塩素欠乏は腎臓におけるHCO3-再吸収を刺激(ICU.489)

アニオンギャップ(AG=[Na+] - [HCO3-] - [Cl-])を保つようにHCO3-が増加したと考えればよいのか。

原因による分類

ICU.493

塩素反応性：尿中塩素＜15mEq/L

1. 胃酸の喪失　→　H+, Cl-の喪失
2. 利尿薬　→　多くの利尿剤でCl-を喪失(see. 利尿薬)
3. 循環血液量不足
4. 高二酸化炭素症に対する腎性の代償：CO2↑　→　腎で代償的にHCO3-排泄↓　→　(おそらく)HCO3-の代替としてCl-が排泄

塩素抵抗性：尿中塩素＞25mEq/L

1. ミネラルコルチコイド過剰：尿細管でNa+再吸収、K+排泄亢進。体内では代償的に細胞外へのK+放出、細胞内へのH+取り込みが起こる　→　代謝性アルカローシス
2. カリウム欠乏

YN.D-155

腎からのH+喪失、重炭酸再吸収の亢進：糖質コルチコイド・鉱質コルチコイド投与、アルドステロン症、クッシング症候群、腎血管性高血圧、バーター症候群、ギテルマン症候群
細胞内へのH+移動：
消化管からのH+喪失：嘔吐、胃管による消化液吸引、慢性下痢、先天性塩類漏出症
NaCl喪失に伴う細胞外液の喪失
その他

炭酸水素ナトリウム過剰投与
ミルクアルカリ症候群
高カルシウム血症
大量輸液　　→　　抗凝固薬として加えられているクエン酸が代謝されて重炭酸イオンが形成される　　←　　どう考えてもこの代謝pathが分からない。
refeeding syndrome

水・電解質と酸塩基平衡改訂第2版 p.163

I. H+の喪失

1. 消化管からの喪失

胃液への排出(嘔吐、胃液吸引)

2. 尿中への喪失

鉱質コルチコイド過剰

利尿薬

多量のカルベニシリンなどのペニシリン誘導体等よ

高カルシウム血症

3. H+の細胞内への移行

低カリウム血症

II. HCO3-の投与

大量の輸液(大量のクエン酸摂取による)

NaHCO3の投与

ミルク・アルカリ症候群

III. contraction alkalosis

出典不明

腎でのH+再吸収低下(硫酸イオン、高カルシウム血症、副甲状腺機能低下症、ペニシリン)

症例

16歳女性、神経過食症であり、自己誘発性嘔吐を制御できなかった。この女性で予想されるK, HCO3-の状態は？

国試

103A016

「低リン血症」

　　[★]

英: hypophosphatemia、hypophosphataemia
同: (国試)低リン血症、低P血症
関: リン。低リン血症性。低リン血症性。hypophosphatemic、hypophosphataemic

[show details]

低リン酸血症 hypophosphatemia : 約 52 件
低リン血症 hypophosphatemia : 約 83 件

低リン酸血症 : 約 86 件
低リン血症 : 約 313,000 件

概念

循環血液中のリン酸塩濃度値が低い状態。

原因

uptodate

改変

生体内での再分布

インスリン分泌の増加：特にrefeeding syndrome：飢餓状態から急に末梢血にブドウ糖が供給されると、インスリン、ブドウ糖と共にリン酸が細胞内に移動し細胞内で盛んにATP産生が行われるが、この結果末梢血のリン酸濃度が低下する。
糖尿病性ケトアシドーシス
急性呼吸性アルカローシス：血液のpHが上昇するとホスホフルクトキナーゼの活性が亢進するため、血液中のリン酸が細胞内に取り込まれる結果、低リン血症を来す
飢餓骨症候群(hungry bone syndrome)：副甲状腺機能亢進状態から正常に復帰後、骨から放出されていたリン酸とカルシウムを再吸収し骨形成が進む結果、末梢血のリン酸濃度が低下する。
急性アルコール中毒
高カロリー輸液

腸管からの吸収低下

摂取量低下
リン酸の吸収を阻害する薬剤の摂取(制酸剤(アルミニウム制酸剤)、リン酸結合物質(炭酸カルシウム)、ナイアシンなど)
嘔吐
脂肪便、下痢
吸収不良症候群
ビタミンD欠乏、ビタミンD抵抗性

尿からの排泄増加

腎代替療法による除去

臨床関連

リンは骨や歯を形成するのに不可欠な物質であり、血清リン酸の低下が持続すると骨石灰化障害を来す

参考

Hypophosphatemia - Sandeep Sharma; Muhammad F. Hashmi; Danny Castro.

https://www.ncbi.nlm.nih.gov/books/NBK493172/

「リフィーディング症候群」

　　[★]

英: refeeding syndrome
同: 再栄養症候群、refeeding症候群

飢餓状態から急激に栄養補給することに起因する低リンを伴う全身症状

原因

アルコール中毒
拒食症
高血糖
敗血症
甲状腺切除後

症状

イライラ、倦怠感、筋力低下、代謝性脳症、横紋筋融解症、低血圧、心室性不整脈、溶血性貧血

「syndrome」

　　[★]

n.

症候群

[pmid18583681-1] Mehanna HM, Moledina J, Travis J (June 2008). "Refeeding syndrome: what it is, and how to prevent and treat it". BMJ 336 (7659): 1495–8. doi:10.1136/bmj.a301. PMC 2440847. PMID 18583681.

[2] Schnitker MA, Mattman PE, Bliss TL. A clinical study of malnutrition in Japanese prisoners of war. Ann Intern Med 1951;35: 69-96 PMID 14847450

[pmid14847450-3] SCHNITKER MA, MATTMAN PE, BLISS TL (July 1951). "A clinical study of malnutrition in Japanese prisoners of war". Annals of Internal Medicine 35 (1): 69–96. doi:10.7326/0003-4819-35-1-69. PMID 14847450.

[4] ttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440847/

[5] Webb GJ et al., Complications of emergency refeeding in anorexia nervosa: case series and review. Acute Medicine 2011;10(2):69-76. http://www.ncbi.nlm.nih.gov/pubmed/22041604

[6] Assiotisa A, Elenin, H. Implications of refeeding syndrome in posteropative total parenteral nutrition. Grand Rounds 10 63-66, 2010 http://www.grandrounds-e-med.com/articles/gr100013.htm

匿名

検索

案内

refeeding syndrome