Acute thiamine deficiency and refeeding syndrome: Similar findings but different pathogenesis

Nutrition. 2014 Jul-Aug;30(7-8):948-52. doi: 10.1016/j.nut.2014.02.019. Epub 2014 Mar 13.


Objective: Refeeding syndrome can occur in several contexts of relative malnutrition in which an overaggressive nutritional support is started. The consequences are life threatening with multiorgan impairment, and severe electrolyte imbalances. During refeeding, glucose-involved insulin secretion causes abrupt reverse of lipolysis and a switch from catabolism to anabolism. This creates a sudden cellular demand for electrolytes (phosphate, potassium, and magnesium) necessary for synthesis of adenosine triphosphate, glucose transport, and other synthesis reactions, resulting in decreased serum levels. Laboratory findings and multiorgan impairment similar to refeeding syndrome also are observed in acute thiamine deficiency. The aim of this study was to determine whether thiamine deficiency was responsible for the electrolyte imbalance caused by tubular electrolyte losses.

Methods: We describe two patients with leukemia who developed acute thiamine deficiency with an electrolyte pattern suggestive of refeeding syndrome, severe lactic acidosis, and evidence of proximal renal tubular dysfunction.

Results: A single thiamine administration led to rapid resolution of the tubular dysfunction and normalization of acidosis and electrolyte imbalance. This demonstrated that thiamine deficiency was responsible for the electrolyte imbalance, caused by tubular electrolyte losses.

Conclusions: Our study indicates that, despite sharing many laboratory similarities, refeeding syndrome and acute thiamine deficiency should be viewed as separate entities in which the electrolyte abnormalities reported in cases of refeeding syndrome with thiamine deficiency and refractory lactic acidosis may be due to renal tubular losses instead of a shifting from extracellular to intracellular compartments. In oncologic and malnourished patients, individuals at particular risk for developing refeeding syndrome, in the presence of these biochemical abnormalities, acute thiamine deficiency should be suspected and treated because it promptly responds to thiamine administration.

Keywords: Hypophosphatemia; Lactic acidosis; Methotrexate; Refeeding syndrome; Renal tubular dysfunction; Thiamine.

Publication types

  • Case Reports

MeSH terms

  • Acidosis, Lactic / drug therapy*
  • Acidosis, Lactic / etiology
  • Child
  • Electrolytes / metabolism*
  • Female
  • Humans
  • Infant
  • Kidney Tubules / metabolism
  • Kidney Tubules / physiopathology*
  • Leukemia / therapy
  • Male
  • Nutritional Support / adverse effects
  • Refeeding Syndrome / complications
  • Refeeding Syndrome / diagnosis*
  • Thiamine / therapeutic use*
  • Thiamine Deficiency / complications
  • Thiamine Deficiency / diagnosis*
  • Thiamine Deficiency / drug therapy
  • Water-Electrolyte Imbalance / drug therapy*
  • Water-Electrolyte Imbalance / etiology


  • Electrolytes
  • Thiamine