Retrospective evaluation of refeeding syndrome in cats: 11 cases (2013–2019)

Abstract

Objectives The aim of this study was to describe the clinicopathological findings, management and outcome of cats with refeeding syndrome (RS) following prolonged starvation. Methods Records from four referral hospitals were searched between May 2013 and November 2019 and retrospectively evaluated. Inclusion criteria were the presence of a risk factor for RS, such as severe weight loss or emaciation following a period of presumed starvation, hypophosphataemia or a delta phosphorous exceeding 30% reduction following refeeding, being treated on the basis of a clinical diagnosis of RS and one or more derangement of hypokalaemia, hypoglycaemia or hyperglycaemia. Results Eleven cats were identified, which had been missing for a median of 6 weeks (range 3–104 weeks). Mean ± SD percentage weight loss was 46% ± 7% (n = 8). Eight of 11 cats developed hypophosphataemia with a mean delta phosphorous of −47% ± 9%. All cats were documented to be hypokalaemic. During hospitalisation, 10/11 cats developed hyperglycaemia and 7/11 cats developed hypoglycaemia. Cardiovascular, gastrointestinal and neurological signs were common. Eight of 11 cats displayed new or progressive neurological deficits after refeeding, including mentation changes and cerebellar dysfunction. All cats became anaemic and seven cats required a blood transfusion. Eight cats survived to discharge after a mean of 14 ± 4 days of hospitalisation. Six cats developed acute kidney injury (AKI; International Renal Interest Society stage 1). The presence of AKI ( P = 0.024) was associated with non-survival and maximum bilirubin concentration was significantly higher in non-survivors ( P = 0.018). Conclusions and relevance Cats with RS in this cohort had been missing, presumed starved, for more than 3 weeks. In addition to hypophosphataemia and hypokalaemia, altered glucose homeostasis and organ damage involving the liver and kidneys were common. Cats with RS appear to have a good prognosis, but prolonged intensive care is required.

2022 ISFM Consensus Guidelines on Management of the Inappetent Hospitalised Cat

“…Refeeding syndrome occasionally, severely debilitated cats can develop a life-threatening metabolic condition termed 'refeeding syndrome' if fed in excess of what they can process. 127,130 Refeeding syndrome has been reported to occur even after short periods of starvation in human patients; 131 however, in a recent feline case series, affected cats had been missing (presumed starved) for more than 3 weeks. 127 This syndrome is characterised by neuro logical signs (eg, depression, coma), systemic weakness, haemolytic anaemia, glycaemic dysregulation and severe electrolyte abnormalities (eg, hypo kalaemia, hypophosphataemia, hypomagnesaemia) due to insulin-driven glucose uptake.…”

“…Thiamine deficiency may also contribute to neurological signs. 127 If refeeding syndrome is suspected, feeding should cease until the patient is stabilised and the feeding plan adjusted to avoid worsening of this syndrome. Identification of at-risk patients is important and includes cats that have been missing, had a complete lack of food intake, are severely debilitated with significant body condition loss (Figure 20) or those with electrolyte abnormalities prior to commencing feeding.…”

“…5 In more debilitated patients or in the presence of significant morbidity (eg, severe GI dysfunction, major electrolyte and nutrient deficienrcies, severe starvation), a more conservative approach may be necessary and meeting RER may take several additional days. 127 Following stabilisation of nutritional status (ie, stopping further weight loss) and when the cat is in recovery from the primary disease, energy targets can be increased to restore normal body condition.…”

Feline cholangitis/cholangiohepatitis complex

“…For example, diets fed to cats with hepatic encephalopathy or severe azotaemia should have lower protein (3 to 4 g per 100 kcal) (Chan 2020). Regardless of the type of diet, it should be reintroduced slowly as to mitigate the risk for refeeding syndrome (Cook et al 2021). The specific timeline that 100% RER is achieved will vary on a case-by-case basis.…”

“…Regardless of the type of diet, it should be reintroduced slowly as to mitigate the risk for refeeding syndrome (Cook et al . 2021). The specific timeline that 100% RER is achieved will vary on a case‐by‐case basis.…”