Low prealbumin is a significant predictor of medical complications in severe anorexia nervosa

Thrombocytopenia and PT-INR in patients with anorexia nervosa and severe liver dysfunction

BACKGROUND

We previously reported a case that led us to hypothesize that decreased production of thrombopoietin (TPO) leads to thrombocytopenia in patients with anorexia nervosa (AN) with severe liver dysfunction and that prolonged prothrombin time-international normalized ratio (PT-INR) predicts thrombocytopenia in such cases. To validate this hypothesis, we report another case in which TPO levels were measured. In addition, we examined the association between prolonged PT-INR and thrombocytopenia in such patients.

MAIN BODY

Similar to the previously reported patient, a patient with AN with severe liver dysfunction showed that TPO levels increased after improvements in liver enzyme levels and PT-INR, followed by recovery of platelet count. In addition, a retrospective study was also conducted to review patients with AN whose liver enzyme levels were > 3 × the upper limit of normal (aspartate aminotransferase > 120 U/L or alanine aminotransferase > 135 U/L). The study included 58 patients and showed a correlation coefficient of -0.486 (95% confidence interval [CI], -0.661 to -0.260; P < 0.001) between maximum PT-INR and minimum platelet count. These patients showed higher PT-INR (β, 0.07; 95% CI, 0.02 to 0.13; P = 0.005) and lower platelet count (β, -5.49; 95% CI, -7.47 to -3.52; P < 0.001) than the 58 matched control patients without severe liver dysfunction, even after adjusting for body mass index.

CONCLUSIONS

In patients with AN with severe liver dysfunction, prolongation of PT-INR could predict thrombocytopenia, which may be mediated by decreased TPO production due to decreased hepatic synthetic function.

Evaluation of the ASPEN guidelines for refeeding syndrome among hospitalized patients receiving enteral nutrition: A retrospective cohort study

BACKGROUND

Until recently, refeeding syndrome (RFS) has lacked standardized diagnostic criteria. This study sought to (1) determine whether RFS, as operationalized in the 2020 American Society for Parenteral and Enteral Nutrition (ASPEN) guideline definition, is associated with adverse clinical outcomes and (2) identify key risk factors for RFS.

METHODS

In this retrospective cohort study, adults hospitalized from 2015 to 2019 were included if they were ordered for enteral feeding during hospitalization. Data were collected for up to 30 days, and RFS was operationalized as per the ASPEN 2020 guidelines as a ≥10% (corresponding to mild RFS), ≥25% (moderate), and ≥50% (severe) decline in prefeeding serum phosphorus, magnesium, or potassium. The mortality associated with RFS was assessed, and risk factors for RFS were identified using multivariable logistic regression modeling.

RESULTS

Of 3854 participants, 3480 (90%) developed mild RFS. Thirty-day mortality was higher in those without mild RFS (24%) than in those with mild RFS (18%) (P < 0.01). When RFS was reoperationalized as a 50% decline in electrolytes, 25% of patients developed RFS with a 20% 30-day mortality. Risk factors for development of RFS included renal failure, elevated creatinine, and low platelets; additionally, prefeeding serum phosphorus level was strongly associated with development of RFS (adjusted odds ratio, 6.09; 95% confidence interval, 4.95-7.49 for those in the highest tertile of prefeeding phosphorus compared with the lowest).

CONCLUSION

The ASPEN operationalization of RFS as a decline in baseline electrolyte values was not associated with death. Prefeeding serum phosphorus level strongly predicted severe RFS.

[Refeeding syndrome]

Refeeding syndrome (RS) is a rare but severe condition that is poorly understood, often under-diagnosed and can lead to death. It occurs within 5 days after refeeding in patients after prolonged fasting or in a context of undernutrition. As a consequence of the abrupt transition from catabolism to anabolism, RS is defined as a decrease in plasma levels of phosphorus, potassium and/or magnesium, whether or not associated with organ dysfunction resulting from a decrease in one of the electrolytes or a thiamine deficiency, after refeeding. The clinical symptoms are varied and non-specific and are related to hydro electrolyte disorders, sodium-hydroxide retention or failure of one or more organs. Patient management should be appropriate with regular clinical examination and careful biological monitoring, including hydro electrolyte monitoring. The correction of hydroelectrolytic disorders and systematic thiamine supplementation are essential during refeeding, that must be done carefully and very progressively, whatever its form (oral, enteral or parenteral). The severity of the refeeding syndrome indicates that its prevention and screening are the corners of its management in at-risk patients.

[Anorexia nervosa: Abnormalities in hematological and biochemical parameters]

Abnormalities of hematological and biochemical parameters are various and frequent during anorexia nervosa, and are mainly related to malnutrition, weight loss, and compensatory purgative behaviors. They are most often moderate and reversible through appropriate nutritional and weight rehabilitation, as well as well-conducted symptomatic treatment. Severe abnormalities are rarer, but are potentially serious or even fatal. Isolated moderate anemia and leukopenia are frequently noted, with thrombocytopenia being less frequent. Severe, bi-cytopenic, pancytopenic, and spinal cord injury are less common. They can be explained by the gelatinous transformation of the bone marrow caused by malnutrition. Biochemical abnormalities are typically hydroelectrolytic disorders (hypokalemia, hyponatremia, metabolic alkalosis), acute or chronic renal failure, elevated transaminases, risk of potentially severe hypoglycemia, and elevated lipid parameters. During the refeeding syndrome, hypophosphatemia is characteristic and may be associated with hypomagnesemia and hypocalcemia, and thiamine deficiency. Malnutrition can also lead to alterations in hormone status, including hypothyroidism, hypercorticism and hypogonadism, which may be involved in the development of serious bone conditions such as osteoporosis. These abnormalities should be routinely investigated, monitored, and corrected during anorexia nervosa. Early and multidisciplinary management of this eating disorder is essential to prevent chronicity of the disorder and the potential severity of these abnormalities.

Diets with high carbohydrate contents were associated with refeeding hypophosphatemia: A retrospective study in Japanese inpatients with anorexia nervosa

OBJECTIVE

Refeeding hypophosphatemia (RH) is a potentially fatal complication in patients with anorexia nervosa (AN), and its dietary preventive strategy is not well established. We aimed to examine the association between carbohydrate content in the diet and the occurrence of RH in inpatients with AN via retrospective medical chart review.

METHOD

We performed a chart review to collect data of patients with AN hospitalized at the Department of Psychosomatic Medicine of the University of Tokyo Hospital between April 1, 2012, and February 29, 2020. Receiver operating characteristic (ROC) analysis was performed to determine the cutoff point of the percentage of carbohydrate content in the diet for the occurrence of RH. Multivariate logistic regression analysis was performed with occurrence of RH as the dependent variable and the carbohydrate content of more than the identified cutoff point as the independent variable adjusting for the risk factors for RH.

RESULTS

The percentage of carbohydrate content that is higher than the cutoff point obtained from the ROC analysis (58.4%) was significantly associated with the occurrence of RH, even after adjusting for variables associated with RH in univariate logistic regression analysis (age and body mass index) as well as the average daily calorie intake (odds ratio, 5.37; 95% confidence interval, 1.60-18.1; p = .0066).

DISCUSSION

We identified that diets with higher carbohydrate contents were associated with RH in inpatients with AN, even after adjusting for known risk factors. Our findings may promote the development of dietary preventive strategies against RH in inpatients with AN.

Hypophosphatemia in a Specialized Intestinal Failure Unit: An Observational Cohort Study

BACKGROUND

Patients with intestinal failure (IF) are prone to hypophosphatemia and shifts in magnesium and potassium levels. Although these shifts are often attributed to refeeding syndrome (RFS), the incidence of electrolyte shifts among patients with IF is unknown. We evaluated the occurrence of hypophosphatemia and other electrolyte shifts according to the functional and pathophysiological IF classifications.

METHODS

We consecutively included all patients' first admission to an IF unit from 2013 to 2017. Electrolyte shifts were defined as severe hypophosphatemia <0.6 mmol/L (mM) or any 2 other shifts below reference range, comprising hypomagnesemia <0.75 mM, hypophosphatemia <0.8 mM, or hypokalemia <3.5 mM. Outcomes included length of stay, central line-associated bloodstream infection, and other infections. Mortality was evaluated 6 months after discharge.

RESULTS

Of 236 patients with IF, electrolyte shifts occurred in 99 (42%), and 127 (54%) of these patients received intravenous supplementation with either phosphate, magnesium, or potassium. In patients who started parenteral nutrition, up to 62% of early-onset shifts (<5 days) related to refeeding, and up to 63% of late-onset shifts (≥5 days) could be ascribed to infections. Derangements occurred in 7 (18%) with type 1 IF, 53 (43%) with type 2 IF, and 39 (53%) readmitted patients with type 3 IF. Of 133 patients with IF secondary to short-bowel syndrome, 65 (49%) developed shifts.

CONCLUSION

In patients with IF, electrolyte shifts are frequent but not always due to RFS. Electrolyte shifts are common in patients with type 2 and those readmitted with type 3 IF.

Mortality associated with new risk classification of developing refeeding syndrome in critically ill patients: A cohort study

BACKGROUND & AIMS

Although refeeding syndrome (RFS) has been recognized as a potentially fatal metabolic complication, the definition of RFS has remained unclear. Recently, European researchers suggested an evidence-based and consensus-supported algorithm that consisted of a new RFS risk classification and treatment strategies for medical inpatients. The classification was based on the National Institute for Health and Clinical Excellence (NICE) criteria for patients at risk of developing RFS. In this study, we aimed to investigate the frequency of each applied new risk group and the association between the new classification and mortality in critically ill patients.

METHODS

This cohort study was conducted at a Japanese metropolitan tertiary-care university hospital from December 2016 to December 2018. We included critically ill adult patients who were admitted to the intensive care unit (ICU) via the emergency department and who stayed in the ICU for 24 h or longer. We applied the new risk classification based on the NICE RFS risk factors on ICU admission. The main exposure was risk classification of RFS: no risk, low risk, high risk, or very high risk. The primary outcome was in-hospital mortality censored at day 30 after ICU admission. We performed a multivariable analysis using Cox proportional hazard regression.

RESULTS

We analyzed 542 patients who met the eligibility criteria. The prevalence of the four RFS risk classification groups was 25.8% for no risk, 25.7% for low risk, 46.5% for high risk, and 2.0% for very high risk. The 30-day mortality was 5.0%, 7.2%, 16.3%, and 27.3%, respectively (log-rank trend test: p < 0.001). In the multivariable Cox regression, adjusted hazard ratios with no risk group as a reference were 1.28 (95% CI 0.48-3.38) for low risk, 2.81 (95% CI 1.24-6.35) for high risk, and 3.17 (95% CI 0.78-12.91) for very high risk.

CONCLUSIONS

Approximately half the critically ill patients were categorized as high or very high risk based on the new risk classification. Furthermore, as the risk categories progressed, the 30-day in-hospital mortality increased. Early recognition of patients at risk of developing RFS may improve patient outcomes through timely and optimal nutritional treatment.

Computed Tomography-Measured Psoas Muscle Density as a Predictive Factor for Hypophosphatemia Associated With Refeeding

BACKGROUND

Initiation of parenteral nutrition (PN) after a period of starvation can be complicated by refeeding syndrome (RFS). RFS is associated with electrolyte abnormalities including hypomagnesemia, hyponatremia, and hypophosphatemia. Risk factors include recent weight loss, low body mass index, and electrolyte deficiencies; however, these associations are not strong. We hypothesized that a validated measure of nutrition risk, computed tomography (CT)-measured psoas muscle density, can be used to predict the development of hypophosphatemia associated with RFS.

METHODS

A retrospective analysis of surgical patients initiated on PN with an abdominal CT scan within the past 3 months was conducted. CT-measured psoas muscle density was assessed as a predictive variable for the development of electrolyte abnormalities. Daily electrolyte and clinical outcome measures were recorded.

RESULTS

One hundred nine patients were stratified based on Hounsfield unit average calculation (HUAC). The lowest 25th percentile of patients had HUAC <25. Low HUAC was associated with a significant percent decrease in phosphate levels from baseline to PN day 3 (P < .01) and significant difference in serum phosphate value on PN day 3 (P < .01). The low muscle density quartile also experienced longer days on the mechanical ventilator (P = .01) compared with patients with a higher psoas muscle density.

CONCLUSION

Psoas muscle density predicted the development of hypophosphatemia in patients initiated on PN. This measurement may aid in identifying patients at highest risk of experiencing RFS. A mean psoas HU <25 may prompt additional precautions, including additional phosphate replacement and slower initiation of PN.

Medical Complications of Anorexia Nervosa

OBJECTIVE

The purpose of this study was to describe the medical complications of anorexia nervosa (AN) to enable a consult-liaison psychiatrist to be familiar with these complications when involved with the care of a hospitalized patient with AN.

METHODS

Comprehensive PubMed search of English language publications of adult patients with AN was carried out using keywords, phrases, and medical subject headings of anorexia nervosa-medical complications, cardiac, osteoporosis, gastrointestinal, hematological, and endocrine. The database search was restricted by time of publication of studies from 2005 to 2020.

RESULTS

Every organ system can be adversely affected by AN. Most are fully reversible with time and informed medical care. A multidisciplinary team is needed to optimally care for patients who are hospitalized as a result of the medical complications of their AN.

CONCLUSIONS

Consult-liaison psychiatrists are asked to help in the care of patients with AN who are admitted to a hospital because of a medical complication of their illness. Being familiar with these complications and their treatments will optimize their hospital stays and the care provided. In addition, involving other relevant ancillary services is an important care consideration.

Prealbumin: The clinical utility and analytical methodologies

Prealbumin is a small protein which has been widely evaluated as a nutritional and a prognostic marker. The small size and concentration of prealbumin in blood proposes challenges on measuring it with high sensitivity and specificity. Over the years, a number of analytical methodologies have been developed, which may help establish prealbumin as a useful biomarker in routine clinical practice. The aim of the short review was to explore the current literature on the clinical utility of prealbumin and the advances made in the analytical methodologies of prealbumin. We searched MEDLINE, EMBASE and the Cochrane Library for articles published between January 1980 and July 2019, with the general search terms of 'prealbumin', 'prognostic marker', 'nutritional marker', 'analytical methodologies' and 'malnutrition'. Additionally, we selected relevant articles and comprehensive overviews from reference lists of identified studies. The routine use of prealbumin in clinical practice remains debatable; however; it can complement clinical history, anthropometric assessment and physical examination to assess malnutrition with more certainty. Consensus on the clinical applications of prealbumin in the management of malnutrition is warranted.

Extreme anorexia nervosa: medical findings, outcomes, and inferences from a retrospective cohort

BACKGROUND

Extreme anorexia nervosa (AN) is defined as a BMI < 15 kg/m² in those meeting DSM-V diagnostic criteria for AN. This study seeks to define the frequency of medical complications in this group of patients in order to help inform the care of individuals < 65% ideal body weight who seek treatment for their extreme eating disorders.

METHODS

Through retrospective chart review and computerized data collection, we obtained the baseline characteristics and medical findings of 281 adult patients, with AN restricting and binge-purge subtypes, admitted to the ACUTE unit for medical stabilization between May 2013 and August 2018.

RESULTS

In this population, with a mean admitting BMI of 12.1 kg/m² (range = 7.5-15.7), 56% admitted with bradycardia, 45% demonstrated increased liver function tests (LFTs) on admission, 64% admitted with leukopenia, 47% with anemia, and 20% presented with thrombocytopenia. During admission, 38% developed hypoglycemia, 35% developed refeeding hypophosphatemia, nearly 33% of patients developed edema, and low bone mineral density was diagnosed in almost 90% of the patients. Highly elevated LFTs (>3x upper limits of normal) predicted hypoglycemia, and low BMI predicted refeeding hypophosphatemia (p = .001).

CONCLUSIONS

Although conclusions drawn from the findings presented in this descriptive study must be tempered by relevant clinical judgement, these findings showcase that patients with extreme AN are at significantly increased risk for many serious medical complications secondary to their state of malnutrition and also with initial refeeding.

Physical and psychological aspects of anorexia nervosa based on duration of illness: a cross-sectional study

Background

We evaluated physical and psychological features of patients with anorexia nervosa (AN) who differed by duration of illness.

Methods

Data were obtained from 204 female patients with AN, divided into two groups based on illness duration: short-term illness duration (less than 5 years; n = 118); and long-term duration (5 years or more; n = 86). Physical parameters were measured using blood serum testing and psychological aspects were assessed using various instruments.

Results

A significantly higher proportion of restricting type AN was observed in the short-term group while the proportion of binge eating/purging type AN was higher in the long-term group. There was no difference in body mass index (BMI) between the groups. Serum total protein, albumin, potassium, chloride, and calcium in the long-term group were significantly lower than in the short-term group. Overall scores on the Eating Disorder Inventory as well as most of the subscales, except maturity fears, were higher in the long-term group than in the short-term group. The care subscale of the Parental Bonding Instrument (PBI) was lower in the long-term group than in the short-term group, while the overprotection subscale of the PBI was higher in the long-term group than in the short-term group. Results of a multiple regression analysis indicated that the overprotection subscale of the PBI was the only significant predictor of duration of illness.

Conclusions

Duration of illness may be associated with physical and psychological features of AN; thus, adapting therapeutic approaches to illness duration might be necessary.

Management of Refeeding Syndrome in Medical Inpatients

Refeeding syndrome (RFS) is the metabolic response to the switch from starvation to a fed state in the initial phase of nutritional therapy in patients who are severely malnourished or metabolically stressed due to severe illness. It is characterized by increased serum glucose, electrolyte disturbances (particularly hypophosphatemia, hypokalemia, and hypomagnesemia), vitamin depletion (especially vitamin B1 thiamine), fluid imbalance, and salt retention, with resulting impaired organ function and cardiac arrhythmias. The awareness of the medical and nursing staff is often too low in clinical practice, leading to under-diagnosis of this complication, which often has an unspecific clinical presentation. This review provides important insights into the RFS, practical recommendations for the management of RFS in the medical inpatient population (excluding eating disorders) based on consensus opinion and on current evidence from clinical studies, including risk stratification, prevention, diagnosis, and management and monitoring of nutritional and fluid therapy.

Body mass index cut-off point associated with refeeding hypophosphatemia in adults with eating disorders

OBJECTIVE

Refeeding hypophosphatemia (RH) is a life-threatening complication in underweight patients with eating disorders (EDs). Although a lower body mass index (BMI) has been reported as a risk factor for RH, the exact BMI cut-off point is not known. Herein, we aimed to identify the optimal BMI cut-off point for RH in adults with EDs.

METHOD

The medical charts of Japanese inpatients with EDs at our hospital between April 1, 2012 and March 31, 2017 were retrospectively reviewed. The optimal BMI cut-off point for RH was determined via receiver operating characteristic analysis. Logistic regression analysis was subsequently performed to assess the association between RH and the BMI cut-off point after adjusting for the propensity score, which was based on known risk factors for RH.

RESULTS

The optimal BMI cut-off point was identified as 12.6 kg/m² . A BMI lower than the cut-off point significantly correlated with the occurrence of RH after adjusting for the propensity score.

DISCUSSION

The optimal BMI cut-off point for the occurrence of RH was 12.6 kg/m² in adults with EDs. The findings of the present study may facilitate clinical decision making and early identification of patients who require prophylactic treatment for RH.

An update on the medical consequences of anorexia nervosa

PURPOSE OF REVIEW

The diagnosis of anorexia nervosa is associated with the highest mortality rate of any psychiatric disorder, mainly caused by medical complications.The purpose of this article is to review the common medical consequences of anorexia nervosa focusing on the special considerations related to children and adolescents and recent updates on the pathophysiology of these complications and their prognosis significance.

RECENT FINDINGS

The main findings were related to the diagnostic and prognostic value of hypokalaemia, QTc prolongation, hypoglycaemia and orthostatic changes. A new modality to evaluate the heart in anorexia nervosa was explored (2DSTE) as well. Bone mineral density (BMD) loss is one of the few nonreversible consequences of anorexia nervosa. BMD loss does not seem to be significantly related to sex or to cut-off low-weight parameters in teenagers with anorexia nervosa, but rather to the amount of weight loss they have experienced. Brain volume deficits might be another irreversible complication in adolescents with anorexia nervosa.

SUMMARY

It is crucial for any healthcare provider to be informed about the medical consequences of anorexia nervosa, not only because they can be devastating, but also because they can play an essential role in motivating patients to get treated.

Nutritional Management and Outcomes in Malnourished Medical Inpatients: Anorexia Nervosa

BACKGROUND

Anorexia Nervosa (AN) is a psychiatric disorder characterised by a physical and psychosocial deterioration due to an altered pattern on the intake and weight control. The severity of the disease is based on the degree of malnutrition. The objective of this article is to review the scientific evidence of the refeeding process of malnourished inpatients with AN; focusing on the clinical outcome.

METHODS

We conducted an extensive search in Medline and Cochrane; on April 22; 2019; using different search terms. After screening all abstracts; we identified 19 papers that corresponded to our inclusion criteria.

RESULTS

The article focuses on evidence on the characteristics of malnutrition and changes in body composition; energy and protein requirements; nutritional treatment; physical activity programmes; models of organisation of the nutritional treatment and nutritional support related outcomes in AN patients.

CONCLUSION

Evidence-based standards for clinical practice with clear outcomes are needed to improve the management of these patients and standardise the healthcare process.

Refeeding in anorexia nervosa

Refeeding in anorexia nervosa is a collaborative enterprise involving multidisciplinary care plans, but clinicians currently lack guidance, as treatment guidelines are based largely on clinical confidence rather than more robust evidence. It seems crucial to identify reproducible approaches to refeeding that simultaneously maximize weight recovery and minimize the associated risks, in addition to improving long-term weight and cognitive and behavioral recovery and reducing relapse rates. We discuss here various approaches to refeeding, including, among others, where, by which route, how rapidly patients are best refed, and ways of choosing between them, taking into account the precautions or the potential effects of medication or of psychological care, to define better care plans for use in clinical practice.Conclusion: The importance of early weight gain for long-term recovery has been demonstrated by several studies in both outpatient and inpatient setting. Recent studies have also provided evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Finally, the risks of undernutrition/"underfeeding syndrome" and a maintenance of weight suppression are now better identified. Greater caution should still be applied for more severely malnourished < 70% average body weight and/or chronically ill, adult patients. What is Known: • Refeeding is a central part of the treatment in AN and should be a multidisciplinary and collaborative enterprise, together with nutritional rehabilitation and psychological support, but there are no clear guidelines on the management of refeeding in clinical practice. • The risk of a refeeding syndrome is well known and well managed in severely malnourished patients ("conservative approaches"). What is New: • There is evidence that early weight restoration has an impact on outcome, justifying an aggressive approach to refeeding in the early stages of the illness. • The risks of "underfeeding syndrome" and of a maintenance of weight suppression are now better identified and there is sufficient evidence to support a switch in current care practices for refeeding from a conservative approach to higher calorie refeeding. Graphical abstract.

Refeeding syndrome in the frail elderly population: prevention, diagnosis and management

Aging is linked to physiological and pathophysiological changes. In this context, elderly patients often are frail, which strongly correlates with negative health outcomes and disability. Elderly patients are often malnourished, which again is an independent risk factor for both frailty and adverse clinical outcomes. Malnutrition and resulting frailty can be prevented by adequate nutritional interventions. Yet, use of nutritional therapy can also have negative consequences, including a potentially life-threatening metabolic alteration called refeeding syndrome (RFS) in high-risk patients. RFS is characterized by severe electrolyte shifts (mainly hypophosphatemia, hypomagnesemia and hypokalemia), vitamin deficiency (mainly thiamine), fluid overload and salt retention leading to organ dysfunction and cardiac arrhythmias. Although the awareness of malnutrition among elderly people is well established, the risk of RFS is often neglected, especially in the frail elderly population. This partly relates to the unspecific clinical presentation and laboratory changes in the geriatric population. The aim of this review is to summarize recently published recommendations for the management of RFS based on current evidence from clinical studies adapted with a focus on elderly patients.

The Investigation of the Use of Prealbumin as a Tool for Nutritional Assessment in Adults Coinfected with HIV and Intestinal Helminth Parasites in KwaZulu-Natal, South Africa

Serum prealbumin is considered to be as important as albumin in the nutritional status assessment. However, there is relatively little evidence of its advantage over the commonly used albumin. This study investigated the use of prealbumin compared to albumin as a marker of nutritional status in adults singly and dually infected with human immunodeficiency virus (HIV) and intestinal helminths, with or without inflammatory conditions, in different body mass index (BMI) categories. This cross-sectional study was conducted in a periurban setting in KwaZulu-Natal, South Africa. Multivariate multinomial logistic regression models were fitted to investigate the effect of prealbumin and albumin in nutritional assessment among HIV and helminth individuals with or without inflammation, indicated by elevated and normal C-reactive protein (CRP) levels. In normal CRP, albumin was significantly lower in unadjusted BMI [RRR = 0.8, p = 0.001] and in normal weight [RRR = 0.7, p = 0.003] and overweight [RRR = 0.5, p = 0.001] participants. In elevated CRP, albumin was significantly lower [RRR = 0.8, p = 0.050] and prealbumin was significantly higher in unadjusted BMI [RRR = 1.2, p = 0.034] and overweight [RRR = 1.4, p = 0.052] individuals. The current study found that prealbumin can differentiate between inflammation-induced reduction of albumin and true malnutrition in adults singly or coinfected with HIV and intestinal helminths in the presence or absence of inflammation in various BMI categories.

A Higher-Calorie Refeeding Protocol Does Not Increase Adverse Outcomes in Adult Patients with Eating Disorders

BACKGROUND

Patients with eating disorders (EDs) are often considered a high-risk population to refeed. Current research advises using "start low, go slow" refeeding methods (∼1,000 kcal/day, advancing ∼500 kcal/day every 3 to 4 days) in adult patients with severe EDs to prevent the development of refeeding syndrome (RFS), typically characterized by decreases in serum electrolyte levels and fluid shifts.

OBJECTIVE

To compare the incidence of RFS and related outcomes using a low-calorie protocol (LC) (1,000 kcal) or a higher-calorie protocol (HC) (1,500 kcal) in medically compromised adult patients with EDs.

DESIGN

This was a retrospective pre-test-post-test study.

PARTICIPANTS/SETTING

One hundred and nineteen participants with EDs, medically admitted to a tertiary hospital in Brisbane, Australia, between December 2010 and January 2017, were included (LC: n=26, HC: n=93). The HC refeeding protocol was implemented in September 2013.

MAIN OUTCOME MEASURES

Differences in prevalence of electrolyte disturbances, hypoglycemia, edema, and RFS diagnoses were examined.

STATISTICAL ANALYSIS PERFORMED

χ² tests, Kruskal-Wallis H test, analysis of variance, and independent t tests were used to compare data between the two protocols.

RESULTS

Descriptors were similar between groups (LC: 28±9 years, 96% female, 85% with anorexia nervosa, 31% admitted primarily because of clinical symptoms of exacerbated ED vs HC: 27±9 years, 97% female, 84% with anorexia nervosa, 44% admitted primarily because of clinical symptoms of exacerbated ED, P>0.05). Participants refed using the LC protocol had higher incidence rates of hypoglycemia (LC: 31% vs HC: 10%, P=0.012), with no statistical or clinical differences in electrolyte disturbances (LC: 65% vs HC: 45%, P=0.079), edema (LC: 8% vs HC: 6%, P=0.722) or diagnosed RFS (LC: 4% vs HC: 1%, P=0.391).

CONCLUSIONS

A higher-calorie refeeding protocol appears to be safe, with no differences in rates of electrolyte disturbances or clinically diagnosed RFS and a lower incidence of hypoglycemia. Future research examining higher-calorie intakes, similar to those studied in adolescent patients, may be beneficial.

Medical findings in 1,026 consecutive adult inpatient-residential eating disordered patients

OBJECTIVE

Eating disorders are associated with multiple medical complications. We report contemporary medical data, for newly admitted adult inpatient and residential level of care patients.

METHOD

Medical records of a transdiagnostic sample of 1,026 patients, with eating disorders, were retrospectively reviewed for the presence of a broad array of medical complications at time of admission. The prevalence of physiologically relevant medical complications was assessed across major eating disorder categories.

RESULTS

Of the patients, 93.6% were female, and they had an average age of 28.1 (SD = 10.1, range 17-69). The average admission body mass index was 16.1 (SD = 2.3). The prevalence of abnormal laboratory values varied by eating disorder subtype. In patients with anorexia nervosa-restricting subtype, 51.4% had low prealbumin, 36.1% were leukopenic, 34.3% had osteoporosis, 30.0% vitamin D deficiency, 16.8% metabolic alkalosis, 16.0% had hyponatremia, 14.2% hypokalemia, and 7.1% hypoglycemia. These patients had normal average QTc intervals. In patients with anorexia nervosa-binge purging subtype, 42.4% had hypokalemia, 33.3% metabolic alkalosis, osteoporosis in 21.1%, and they had longer QTc intervals (433.9 ms, p < .001). Only 6.0% of patients with anorexia nervosa had hypophosphatemia. Patients with bulimia nervosa demonstrated hypokalemia in 26.2%, and metabolic alkalosis in 23.4%; the QTc interval was longer than in AN-R patients (437.9 ms, p < .001), but still in the normal range.

DISCUSSION

Numerous medical complications are associated with severe eating disorders. As the severity increases, the number of complications increase and are related to the presence or absence of purging behaviors.

Hepatic Complications of Anorexia Nervosa

Anorexia nervosa (AN) has the highest mortality rate of all psychiatric illnesses due to the widespread organ dysfunction caused by the underlying severe malnutrition. Starvation causes hepatocyte injury and death leading to a rise in aminotransferases. Malnutrition-induced hepatitis is common among individuals with AN especially as body mass index decreases. Acute liver failure associated with coagulopathy and encephalopathy can rarely occur. Liver enzymes may also less commonly increase as part of the refeeding process due to hepatic steatosis and can be distinguished from starvation hepatitis by the finding of a fatty liver on ultrasonography. Individuals with AN and starvation-induced hepatitis are at increased risk of hypoglycemia due to depleted glycogen stores and impaired gluconeogenesis. Gastroenterology and hepatology consultations are often requested when patients with AN and signs of hepatitis are hospitalized. It should be noted that additional laboratory testing, imaging, or liver biopsy all have low diagnostic yield, are costly, and potentially invasive, therefore, not generally recommended for diagnostic purposes. While the hepatitis of AN can reach severe levels, a supervised increase in caloric intake and a return to a healthy body weight often quickly lead to normalization of elevated aminotransferases caused by starvation.

Management and prevention of refeeding syndrome in medical inpatients: An evidence-based and consensus-supported algorithm

OBJECTIVES

Refeeding syndrome (RFS) can be a life-threatening metabolic condition after nutritional replenishment if not recognized early and treated adequately. There is a lack of evidence-based treatment and monitoring algorithm for daily clinical practice. The aim of the study was to propose an expert consensus guideline for RFS for the medical inpatient (not including anorexic patients) regarding risk factors, diagnostic criteria, and preventive and therapeutic measures based on a previous systematic literature search.

METHODS

Based on a recent qualitative systematic review on the topic, we developed clinically relevant recommendations as well as a treatment and monitoring algorithm for the clinical management of inpatients regarding RFS. With international experts, these recommendations were discussed and agreement with the recommendation was rated.

RESULTS

Upon hospital admission, we recommend the use of specific screening criteria (i.e., low body mass index, large unintentional weight loss, little or no nutritional intake, history of alcohol or drug abuse) for risk assessment regarding the occurrence of RFS. According to the patient's individual risk for RFS, a careful start of nutritional therapy with a stepwise increase in energy and fluids goals and supplementation of electrolyte and vitamins, as well as close clinical monitoring, is recommended. We also propose criteria for the diagnosis of imminent and manifest RFS with practical treatment recommendations with adoption of the nutritional therapy.

CONCLUSION

Based on the available evidence, we developed a practical algorithm for risk assessment, treatment, and monitoring of RFS in medical inpatients. In daily routine clinical care, this may help to optimize and standardize the management of this vulnerable patient population. We encourage future quality studies to further refine these recommendations.

Permissive Underfeeding or Standard Enteral Feeding in High- and Low-Nutritional-Risk Critically Ill Adults. Post Hoc Analysis of the PermiT Trial

RATIONALE

The optimal nutritional strategy for critically ill adults at high nutritional risk is unclear.

OBJECTIVES

To examine the effect of permissive underfeeding with full protein intake compared with standard feeding on 90-day mortality in patients with different baseline nutritional risk.

METHODS

This is a post hoc analysis of the PermiT (Permissive Underfeeding versus Target Enteral Feeding in Adult Critically Ill Patients) trial.

MEASUREMENTS AND MAIN RESULTS

Nutritional risk was categorized by the modified Nutrition Risk in Critically Ill score, with high nutritional risk defined as a score of 5-9 and low nutritional risk as a score of 0-4. Additional analyses were performed by categorizing patients by body mass index, prealbumin, transferrin, phosphate, urinary urea nitrogen, and nitrogen balance. Based on the Nutrition Risk in Critically Ill score, 378 of 894 (42.3%) patients were categorized as high nutritional risk and 516 of 894 (57.7%) as low nutritional risk. There was no association between feeding strategy and mortality in the two categories; adjusted odds ratio (aOR) of 0.84 (95% confidence interval [CI], 0.56-1.27) for high nutritional risk and 1.01 (95% CI, 0.64-1.61) for low nutritional risk (interaction P = 0.53). Findings were similar in analyses using other definitions, with the exception of prealbumin. The association of permissive underfeeding versus standard feeding and 90-day mortality differed when patients were categorized by baseline prealbumin level (≤0.10 g/L: aOR, 0.57 [95% CI, 0.31-1.05]; >0.10 and ≤0.15 g/L: aOR, 0.79 [95% CI, 0.42-1.48]; >0.15 g/L: aOR, 1.55 [95% CI, 0.80, 3.01]; interaction P = 0.009).

CONCLUSIONS

Among patients with high and low nutritional risk, permissive underfeeding with full protein intake was associated with similar outcomes as standard feeding.

A comparison of the metabolic complications and hospital course of severe anorexia nervosa by binge-purge and restricting subtypes

This study examines adult patients with severe, life-threatening anorexia nervosa who were admitted to an inpatient, medical stabilization unit between October 1, 2008 and December 31, 2014. Specifically, the study compares anorexia nervosa, binge purge subtype (AN-BP) and anorexia nervosa, restricting subtype (AN-R) on admission measures, hospital course, and outcomes. Of the 232 patients, 46% (N = 108) had AN-BP. Patients with AN-R manifested a higher frequency of underweight-mediated medical complications, including bone marrow dysfunction, hepatic dysfunction, and hypoglycemia. Understanding the pathophysiologic differences between severe AN-R and AN-BP is essential to understanding the abnormalities seen on clinical presentation, guiding appropriate clinical treatment, and predicting medical complications during refeeding.

Nurse Assessment of Nutritional Status to Identify Patients at Risk for Complications After Pancreatic Resection

Purpose/Objectives: To determine if serum prealbumin (PAB) levels can be used by nurses to predict patients who may be at higher risk for postoperative complications after pancreatic surgeries. Design: A quantitative, retrospective study. Setting: One cancer center at an urban medical center in Detroit, Michigan. Sample: A convenience sample of 41 patients with resectable pancreatic neoplasms. Methods: Descriptive study with cross-sectional data using chart review to obtain preoperative PAB levels and perioperative data. Main Research Variables: Pancreatic leak, chyle leak, gastroparesis, sepsis, heart attack, length of hospital stay, and readmissions. Findings: There was a higher incidence of pancreatic leak reported after a distal pancreatectomy; however, this complication was not associated with a low PAB of ≤20 mg/dl. Patients with a diagnosis of adenocarcinoma or who underwent a pancreaticoduodenectomy experienced a longer hospital stay. Conclusions: Results did not reinforce the relationship between preoperative nutritional status and outcomes in pancreatic surgery. Implications for Nursing: Surgical oncology nurses should be aware of the importance of presurgical risk assessment and optimization. Tailored implementation of nutritional prehabilitation to improve patient outcomes after resection of pancreatic neoplasms should be studied more comprehensively.

Serum prealbumin as an effective prognostic indicator for determining clinical status and prognosis in patients with hemorrhagic stroke

Serum prealbumin is a recognized marker of malnutrition, but its prognostic role in patients with hemorrhagic stroke remains unclear. In this study, we retrospectively reviewed the records of 105 patients with hemorrhagic stroke admitted to Renmin Hospital of Wuhan University, China, from January to December 2015. We collected demographic and radiological data, and recorded serum prealbumin levels at admission and on days 1, 3, 6, 9, and 14–21. The existence of infections and gastrointestinal hemorrhage, and clinical condition at discharge were also recorded. Serum prealbumin levels during hospitalization were significantly lower in patients with infections compared with those without infections, and also significantly lower in patients with gastrointestinal hemorrhage compared with those without. Serum prealbumin levels at discharge were significantly higher in patients with good recovery than in those with poor recovery. We conclude that regular serum prealbumin measurements in patients with hemorrhagic stroke may be a useful indicator for determining clinical status and prognosis, which may therefore help to guide clinical decision-making.

Concentrations of prealbumin and some appetite-controlling hormones in pregnancies associated with hyperemesis gravidarium

Background Hyperemesis gravidarum, which affects 0.3-2.3% of pregnancies, is defined as excessive vomiting during pregnancy and usually starts in week 4 or 5 of gestation. Symptoms include weight loss, dehydration, ketonaemia, ketonuria, fasting acidosis, alkalosis due to hydrochloric acid loss and hypokalaemia and its exact cause is unknown. The present study was undertaken to investigate the relationship between prealbumin, ghrelin, nesfatin-1 and obestatin concentrations in pregnancies associated with hyperemesis gravidarum. Methods A total of 40 pregnant females with hyperemesis gravidarum and 38 pregnant females without hyperemesis gravidarum as controls were included in this study. Serum concentrations of prealbumin, ghrelin, obestatin and nesfatin-1 were measured. Results There were no significant differences in age, gestational week, gravidity and parity between the two groups. Body mass index was significantly lower in cases than in controls. Serum ghrelin and prealbumin concentrations were significantly lower in cases than in controls ( P  <0.05 and P < 0.001, respectively). There was no significant difference in serum concentrations of obestatin and nesfatin-1 between the two groups. There was no significant association between body mass index and serum ghrelin, nesfatin-1, obestatin or prealbumin concentrations in patients with hyperemesis gravidarum. Conclusions Decreased serum concentrations of ghrelin and prealbumin in patients with hyperemesis gravidarum are independent of body mass index. Based on our results, we believe that ghrelin may be considered to play a role in the aetiopathogenesis of hyperemesis gravidarum and that hyperemesis gravidarum may result in disruption of the relationship between nesfatin-1 and ghrelin. In addition, we believe that the measurement of serum prealbumin may be used for assessing nutritional status in pregnancy.

Role of Prealbumin as a Powerful and Simple Index for Predicting Postoperative Complications After Gastric Cancer Surgery

BACKGROUND

Preoperative factors, including nutritional status, may have strong correlations with postoperative morbidities. The current study evaluated preoperative prealbumin concentrations as a predictor of postoperative complications after gastric surgery.

METHODS

A retrospective study of 1798 patients who underwent gastrectomy for gastric adenocarcinoma was performed. Information was collected on basic patient characteristics, preoperative laboratory findings, and 30 day postoperative complications. The patients were divided into three groups based on prealbumin concentrations (≥22 mg/dL, <22 to ≥15 mg/dL, and <15 mg/dL) for analysis.

RESULTS

The overall complication rate was 21.7 %, and the infection rate was 16 %. Subgroup analysis based on prealbumin concentrations showed that complication rates were markedly elevated with decreasing concentrations of prealbumin. Multivariate analysis using a logistic regression model showed that both overall and infectious complications were strongly associated with male gender, elevated C-reactive protein (CRP), and decreased prealbumin levels (p < 0.05). Even in patients with a CRP level higher than 0.1 mg/dL, male gender and low prealbumin concentrations (<15 mg/dL) were significantly correlated with overall and infectious morbidities (p < 0.05).

CONCLUSIONS

Preoperative prealbumin concentrations are useful predictors of short-term postoperative outcomes after gastrectomy.

Prophylactic Phosphate Supplementation for the Inpatient Treatment of Restrictive Eating Disorders

PURPOSE

The medical stabilization of adolescent patients with restrictive eating disorders can be associated with refeeding syndrome, a potentially fatal complication preceded by refeeding hypophosphatemia (RH). Whether RH can be prevented by routine prophylactic phosphate supplementation has not been previously examined. This study sought to determine the safety and efficacy of a refeeding strategy that incorporates prophylactic phosphate supplementation to prevent RH.

METHODS

Retrospective chart data were collected for patients aged younger than 18 years with restrictive eating disorders admitted to a tertiary pediatric inpatient ward between January 2011 and December 2014. All patients were refed with a standardized protocol that included prophylactic oral phosphate supplementation (1.0 ± .2 mmol/kg/day).

RESULTS

During the 4-year study period, 75 admissions (70 patients) were included for analysis. The mean age and percent median body mass index of included patients were 15.3 years and 83.5%, respectively. Seven out of 75 (9%) had percent median body mass index of <70% and 26 out of 75 (35%) had percent body weight loss >20%. All patients were normophosphatemic at the time of admission (mean serum phosphate 1.24 ± .2 mmol/L). Serial laboratory evaluation revealed that all supplemented patients maintained serum phosphate levels >1.0 mmol/L during the initial 7 days of refeeding. Eleven patients became mildly hyperphosphatemic (range 1.81-2.17 mmol/L) with no associated clinical consequences. Additional analysis of 11 patients presenting with hypophosphatemia before refeeding revealed that with supplementation, phosphate values normalized by Day 1, and this group experienced no further RH episodes during initial refeeding.

CONCLUSIONS

Prophylactic oral phosphate supplementation appears safe, and no episodes of RH occurred in patients with restrictive eating disorders undergoing inpatient refeeding.

Medical outcomes for adults hospitalized with severe anorexia nervosa: An analysis by age group

OBJECTIVE

Relatively little has been written about the outcomes of medical stabilization, analyzed specifically across the age spectrum, in adults with severe anorexia nervosa (AN).

METHOD

We retrospectively evaluated clinical parameters relevant to acuity of illness and outcomes of early refeeding in 142 adults with severe AN, admitted for definitive inpatient medical stabilization from October 1, 2008 to December 31, 2012. Patients were categorized into three age groups: 17 to 29, 30 to 40, and 41+ years.

RESULTS

The study included 142 patients with median age of 28 years old (range 17-65 years). Fifty-four percent (n = 78) were under 30 years old, 23% (n = 32) between 30 and 40 years old, and 23% (n = 32) were over 40 years old. Average admission BMI did not differ among age groups, ranging from 12.7 to 13.2 kg/m(2). Of the admission parameters, only low serum albumin levels (more prevalent in older patients), high international normalized ratio (INR) levels (more prevalent in younger patients), and neutropenia (more prevalent in the <30 age group) varied with age. During hospitalization, rates of bradycardia, hypoglycemia, liver dysfunction, very low %IBW, refeeding hypophosphatemia, refeeding edema, length of stay, and discharge BMI did not differ with age. Age group was associated with rate of weekly weight gain only in patients with AN-binge purge subtype.

DISCUSSION

Results demonstrate medical abnormalities and response to medical stabilization in severely ill AN patients during hospitalization were mostly similar across the age span. This information should allay fears that the effect of age will make medical stabilization more difficult.

Albumin and pre-albumin levels do not reflect the nutritional status of female adolescents with restrictive eating disorders

AIM

Albumin and pre-albumin are frequently used as nutritional markers in clinical practice. We examined whether serum albumin and pre-albumin were predicted by body mass index (BMI), hydration and/or inflammation in female adolescents with a recently diagnosed restrictive eating disorder (RED).

METHODS

This was a retrospective study of female adolescents with RED from 2002 to 2011. Low albumin and pre-albumin levels were defined as <3.5 g/dL and <20 mg/dL, respectively. We assessed inflammation using the erythrocyte sedimentation rate (ESR) and dehydration using the haematocrit levels.

RESULTS

We included 75 females with a mean age of 15.2 years and 64% had a BMI Z score of <-2. The mean albumin and pre-albumin levels were 4.8 g/dL and 22.2 mg/dL, respectively, with 24% of the children having low pre-albumin and none having low albumin levels. The stepwise multiple regression for albumin identified ESR and haematocrit as significant predictors, which explained 14.8% of the variance. Age was the only significant predictor for pre-albumin, which explained 15.3% of the variance.

CONCLUSION

Albumin, but not pre-albumin, levels were primarily predicted by low-grade inflammation and hydration, but not by BMI. These markers should not be used to assess nutritional status in adolescents with RED.

Rare medical manifestations of severe restricting and purging: "Zebras," missed diagnoses, and best practices

OBJECTIVE

Medical problems that arise due to severe restricting and/or purging may be misdiagnosed or suboptimally treated, from outpatient clinics to top medical hospitals. A symptom may be presumed to be a psychological manifestation of the eating disorder and inappropriately dismissed for further medical evaluation. Alternatively, a detailed medical workup may be performed, overlooking a classic relationship between starvation and a physical finding, which delays referral to eating disorder care. This review article focuses on rare medical issues (also called "zebras" in medical training), diagnoses that may be missed in patients with eating disorders, and best practices for management, organized by organ system.

METHOD

A PubMed search was performed, using search terms "eating disorder," "anorexia nervosa," and "bulimia nervosa" in combination with different words for each organ system and known medical manifestations of severe eating disorders, with high quality and relevant studies from the past 20 years cited.

DISCUSSION

Adults with eating disorders may present with extreme organ dysfunction and atypical signs and symptoms of typical medical problems. Timely diagnosis, risk awareness, appropriate treatment, and avoidance of harm are all vital. With judicious management and nutritional rehabilitation, most of these complications will significantly improve or resolve. ©

Liver dysfunction in patients with severe anorexia nervosa

OBJECTIVE

Evaluation of liver dysfunction in patients with severe anorexia nervosa (AN) has typically been limited to small case series. We report an investigation into the admission characteristics and clinical outcomes associated with liver dysfunction in a large cohort of adults hospitalized for medical stabilization of severe AN.

METHODS

We retrospectively evaluated electronic medical records to quantify the cumulative incidence of elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT). We compared mean (±SD), frequencies (%), and median (IQR) values of clinical covariates of interest by incidence of liver enzyme elevation. The study included 181 adults, admitted for medical stabilization of AN, from October 1, 2008 to December 31, 2013.

RESULTS

AST and ALT were mildly elevated in 27.6% of patients and severely elevated (more than three times the upper limit of normal) in 35.4% of patients. On admission, patients with severely elevated liver enzymes had a lower body mass index (BMI) (11.9 ± 1.8 kg/m(2) vs.13.3 ± 1.7 kg/m(2)), lower percentage ideal body weight (56.5% ± 7.7% vs. 63.5% ± 8.3%), and lower prealbumin (64% vs. 37%) compared with the rest of the cohort (p < 0.001). While hospitalized, patients with severely elevated liver enzymes more often developed hypoglycemia, hypophosphatemia, and experienced longer lengths of stay (p < 0.001).

DISCUSSION

Elevated liver enzymes are common in our patient population with severe AN. Liver enzymes reached near normal values by the time of discharge. Severely elevated liver enzymes were associated with a lower BMI and the development of hypoglycemia.

THE ENDOCRINOPATHIES OF MALE ANOREXIA NERVOSA: CASE SERIES

OBJECTIVE

Anorexia nervosa (AN) is a serious disorder with associated morbidity and mortality, most commonly diagnosed in females. Existing literature on male anorexia is sparse, and a review of the endocrine effects of AN in males has not previously been published. Our objective is to highlight the clinical characteristics of AN in males as a routinely overlooked cause of multiple endocrinopathies and systemic illness in hospitalized patients.

METHODS

We present 4 cases (2 cases at The Mount Sinai Hospital; 2 cases at Long Island Jewish Hospital) of young men with hormonal dysfunction due to underlying AN. Pertinent de-identified data were collected from a chart review of cases seen on the endocrinology consult service at both hospitals. Institutional Review Board approval was not required for an observational report of the cases presented.

RESULTS

Four young men with AN demonstrated evidence of multiple systemic complications from severe caloric and protein malnutrition. Varying degrees of endocrinopathies were present, including hypogonadotropic hypogonadism, hypercortisolemia, and nonthyroidal illness syndrome, resulting in bradycardia, gastroparesis, hypothermia, acute systolic heart failure, and erectile dysfunction. Ages at diagnosis were 20, 24, 23, and 20 years, with mean age 21.75 years. Most of the clinical effects from these endocrinopathies resolved with improved caloric intake and nutrition, although symptoms of hypogonadism persisted.

CONCLUSION

This small case series highlights the importance of AN as a potential cause of multiple endocrinopathies in males. The heterogeneous presentations and varying degrees of clinical manifestations in our cohort emphasize the challenge in diagnosis. Increased awareness of AN in males is vital, as its prevalence is likely underestimated and appropriate diagnosis and treatment can ameliorate the metabolic dysfunction in a majority of cases. Further studies on males with eating disorders are needed to help guide diagnostic and therapeutic decisions.

Predictors of hypophosphatemia during refeeding of patients with severe anorexia nervosa

OBJECTIVE

Hypophosphatemia of refeeding is one of the most dangerous complications seen during the treatment of patients with anorexia nervosa. Although easily detectable and treatable, hypophosphatemia is under-recognized as a complication of refeeding. Specific risk factors for the development of hypophosphatemia are likely to exist among patients with severe anorexia nervosa. The purpose of this study was to identify clinically useful markers that may predict the development of or protection from hypophosphatemia during refeeding.

METHODS

We conducted a retrospective case-control study of 123 patients with severe anorexia nervosa admitted for medical stabilization at the ACUTE Center for Eating Disorders between October 1, 2008 and December 31, 2013. Risk factors for refeeding hypophosphatemia were determined by multivariate logistic regression from clinical parameters and laboratory values measured at the time of admission.

RESULTS

The prevalence of hypophosphatemia was 33.3% (41 of 123 patients). Higher hemoglobin was the only risk factor associated with a higher odds of developing hypophosphatemia (adjusted odds ratio [aOR], 1.56 [95% confidence interval [CI], 1.12-2.18]). Statistically significant protective factors against the development of hypophosphatemia were observed with higher body mass index (aOR, 0.54 [95% CI, 0.39-0.75]), higher serum potassium (aOR, 0.29 [95% CI, 0.14-0.62]), and higher serum prealbumin (aOR, 0.91 [95% CI, 0.84-0.99]).

DISCUSSION

Four independent factors associated with refeeding hypophosphatemia were identified. Identification of findings which correlate with hypophosphatemia, or the lack thereof, has the potential to facilitate appropriate triage of patients with anorexia nervosa for closer monitoring during refeeding.

Plasma Transthyretin as a Biomarker of Lean Body Mass and Catabolic States

Plasma transthyretin (TTR) is a plasma protein secreted by the liver that circulates bound to retinol-binding protein 4 (RBP4) and its retinol ligand. TTR is the sole plasma protein that reveals from birth to old age evolutionary patterns that are closely superimposable to those of lean body mass (LBM) and thus works as the best surrogate analyte of LBM. Any alteration in energy-to-protein balance impairs the accretion of LBM reserves and causes early depression of TTR production. In acute inflammatory states, cytokines induce urinary leakage of nitrogenous catabolites, deplete LBM stores, and cause an abrupt decrease in TTR and RBP4 concentrations. As a result, thyroxine and retinol ligands are released in free form, creating a second frontline that strengthens that primarily initiated by cytokines. Malnutrition and inflammation thus keep in check TTR and RBP4 secretion by using distinct and unrelated physiologic pathways, but they operate in concert to downregulate LBM stores. The biomarker complex integrates these opposite mechanisms at any time and thereby constitutes an ideally suited tool to determine residual LBM resources still available for metabolic responses, hence predicting outcomes of the most interwoven disease conditions.

Severe anorexia nervosa in males: clinical presentations and medical treatment

The clinical presentation and medical complications of severe anorexia nervosa among males were examined to further the understanding of this increasingly prevalent condition. Fourteen males were admitted to a medical stabilization unit over the study period. Males with severe anorexia nervosa were found to have a multitude of significant medical and laboratory abnormalities, which are in need of treatment via judicious, nutritional rehabilitation and weight restoration to prevent additional morbidity and to facilitate transfer and admission to traditional eating disorder programs.