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Associations between positive sodium balance and a refeeding-like syndrome following acute abdominal surgery: A

Kim Kristina Mikkelsen¹, Marie Djurhuus¹, Christian Ritz¹

¹Department of Nutrition, Exercise and Sports, University of Copenhagen, Rolighedsvej 26, 1958, Frederiksberg C, Denmark.

Clinical Nutrition ESPEN

|April 26, 2026

Abstract

Background:

Refeeding syndrome (RFS) is conventionally related to initiation of feeding after prolonged semi-starvation. RFS has been observed following acute abdominal surgery and the most frequent manifestations were edema and hypotension. There was no description of weight loss prior to hospitalization and possible adaptation.

Hypothesis:

A positive sodium balance is associated with increased incidence of a refeeding-like syndrome (RLS) in hospitalized adults following acute abdominal surgery.

Method:

This was a prospective cohort study in consecutive patients undergoing acute abdominal surgery. Sodium and phosphate balance was measured daily.

Results:

There was an association and a dose-response relation between a positive sodium balance and development of RLS (p < 0.01). The incidence rate was 1/3.45 person-days with the highest rate in patients with the most positive sodium balance [330-560] mmol/day. 23% developed a drop in p-phosphate and experienced a weight loss lasting at least three months preoperatively which was not correlated to RLS. Patients with a drop in p-phosphate had a larger phosphate excretion (p < 0.05). No correlation between sodium intake and phosphate excretion or sodium and phosphate excretion. More patients undergoing open vs. laparoscopic surgery developed RLS (p < 0.05). Fluid retention was related to high sodium balance. The prevalence of hypotension and edema was related to a more positive sodium balance (p < 0.05).

Conclusion:

These results indicate a dose-response relation between a positive sodium balance and the development of postoperative RLS. The increased phosphate excretion in patients observed with a drop in p-phosphate and the larger number of cases after open surgery is unexplained. Stress-metabolic patients with a decrease in p-phosphate and clinical signs of refeeding syndrome should be treated with sodium restriction but not low calory diets.

Clinicaltrials Registered:

NCT04966780.

Keywords:

Acute abdominal surgery Fluid balance Phosphate excretion Refeeding syndrome Sodium balance

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