{"id":2000,"date":"2024-09-11T14:30:56","date_gmt":"2024-09-11T17:30:56","guid":{"rendered":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/?p=2000"},"modified":"2024-09-11T14:30:56","modified_gmt":"2024-09-11T17:30:56","slug":"hipofosfatemia-sindrome-realiamentacao","status":"publish","type":"post","link":"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/hipofosfatemia-sindrome-realiamentacao\/","title":{"rendered":"Hipofosfatemia e a s\u00edndrome da realimenta\u00e7\u00e3o: o que voc\u00ea sabe sobre essa rela\u00e7\u00e3o?"},"content":{"rendered":"<p>A rela\u00e7\u00e3o entre hipofosfatemia e a s\u00edndrome da realimenta\u00e7\u00e3o deve sempre ser considerada ao abordarmos um paciente que ficou muito tempo em jejum, recebendo baixo aporte nutricional ou mesmo desnutrido, <strong>uma vez que a reintrodu\u00e7\u00e3o da alimenta\u00e7\u00e3o (inclusive por via enteral ou <\/strong><a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/boas-praticas-de-administracao-da-nutricao-parenteral\/\"><strong>parenteral<\/strong><\/a><strong>) est\u00e1 frequentemente associada a essas complica\u00e7\u00f5es<sup>1<\/sup><\/strong>.<\/p>\n<p>Logo, vale entender melhor quais mecanismos desencadeiam a s\u00edndrome de realimenta\u00e7\u00e3o e de que forma quadros de hipofosfatemia est\u00e3o associados a ela. A partir disso, \u00e9 poss\u00edvel delimitar estrat\u00e9gias para reduzir os riscos e gerenciar da melhor forma poss\u00edvel o estado nutricional de pacientes em diferentes condi\u00e7\u00f5es cl\u00ednicas.<\/p>\n<h2>Qual a rela\u00e7\u00e3o entre a hipofosfatemia e a s\u00edndrome da realimenta\u00e7\u00e3o?<\/h2>\n<p>A literatura sobre o assunto mostra que a hipofosfatemia (caracterizada por n\u00edveis de f\u00f3sforo abaixo 0,65 mmol\/L)<sup>2<\/sup> tende a ser causada por quatro mecanismos. Eles envolvem, de maneira direta<sup>3,4<\/sup>:<\/p>\n<ul>\n<li>A redu\u00e7\u00e3o da ingest\u00e3o alimentar e\/ou;<\/li>\n<li>A redu\u00e7\u00e3o da absor\u00e7\u00e3o intestinal e\/ou;<\/li>\n<li>A redistribui\u00e7\u00e3o interna do mineral e\/ou;<\/li>\n<li>Aumento da perda renal.<\/li>\n<\/ul>\n<p>Muitos fatores de predisposi\u00e7\u00e3o para a hipofosfatemia atingem pacientes cr\u00edticos, independentemente da idade. \u00c9 por isso que aten\u00e7\u00e3o redobrada deve ser dispensada para a identifica\u00e7\u00e3o de riscos para a s\u00edndrome de realimenta\u00e7\u00e3o nesse grupo<strong><sup>5<\/sup>.<\/strong><\/p>\n<p>Na pr\u00e1tica, a s\u00edndrome da realimenta\u00e7\u00e3o costuma ser descrita como um dist\u00farbio metab\u00f3lico resultado da introdu\u00e7\u00e3o da nutri\u00e7\u00e3o via enteral ou parenteral em <a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/impacto-desnutricao-preoperatorio\/\">pacientes desnutridos<\/a><sup>6<\/sup>.<\/p>\n<p>A evolu\u00e7\u00e3o do quadro da s\u00edndrome da realimenta\u00e7\u00e3o come\u00e7a com a desnutri\u00e7\u00e3o. A partir disso, h\u00e1 a deple\u00e7\u00e3o dos eletr\u00f3litos intracelulares, como \u00e9 o caso do f\u00f3sforo.<\/p>\n<p>Em seguida, a reintrodu\u00e7\u00e3o de uma terapia nutricional eleva a insulina e reduz a secre\u00e7\u00e3o do glucagon. Por conta disso<strong>, a s\u00edntese de glicog\u00eanio, gordura e prote\u00ednas volta a ser estimulada. Isso exige uma grande quantidade de nutrientes como o f\u00f3sforo, o magn\u00e9sio e a tiamina<sup>7<\/sup>.<\/strong><\/p>\n<p><strong>No fim, o pico de insulina estimula o consumo intracelular de f\u00f3sforo<\/strong>, pot\u00e1ssio e magn\u00e9sio e toda essa cascata de processos reduz a concentra\u00e7\u00e3o dos minerais no sangue<strong>, caracterizando, quando falamos do f\u00f3sforo, a hipofosfatemia<sup>8<\/sup><\/strong>. Diante disso, ela tamb\u00e9m costuma ser chamada de hipofosfatemia de realimenta\u00e7\u00e3o, por estar associada ao processo de realimentar o paciente<sup>6<\/sup>.<\/p>\n<p>A conex\u00e3o entre hipofosfatemia e a s\u00edndrome da realimenta\u00e7\u00e3o \u00e9 sempre destacada porque a defici\u00eancia de f\u00f3sforo tende a ser a altera\u00e7\u00e3o mais not\u00e1vel em tal condi\u00e7\u00e3o cl\u00ednica<sup>9<\/sup>. Logo, esse costuma ser visto como o marcador mais significativo da s\u00edndrome de realimenta\u00e7\u00e3o<sup>9<\/sup>.<\/p>\n<h2>O que se sabe sobre a incid\u00eancia desse tipo de problema?<\/h2>\n<p><strong>\u00c9 preciso sempre destacar que o risco da s\u00edndrome de realimenta\u00e7\u00e3o e da hipofosfatemia deve ser considerado em pacientes de todas as idades e em diferentes contextos cl\u00ednicos. <\/strong><\/p>\n<p>Evid\u00eancias da incid\u00eancia de hipofosfatemia em crian\u00e7as internadas em UTI, por exemplo, mostram que entre 5% e 76% dos pacientes desse perfil podem apresentar o quadro, dependendo do ponto de corte considerado<sup>5<\/sup>.<\/p>\n<p>Do mesmo modo, embora haja d\u00favidas sobre a defini\u00e7\u00e3o da s\u00edndrome de realimenta\u00e7\u00e3o em pacientes neonatais em terapia intensiva, estima-se que entre 20% e 90% desse p\u00fablico tamb\u00e9m apresenta sinais de hipofosfatemia, <a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC8591996\/\">de acordo com uma revis\u00e3o sobre o tema<\/a><sup>10<\/sup>.<\/p>\n<p>Outras evid\u00eancias mostram <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/33829582\/\">o risco do problema em pacientes adultos admitidos em unidades hospitalares por conta de cirurgias de emerg\u00eancia<\/a>. Para isso, um estudo ingl\u00eas reuniu as informa\u00e7\u00f5es de 125 pacientes, que tiveram dados demogr\u00e1ficas e nutricionais coletados<sup>11<\/sup>.<\/p>\n<p>O diagn\u00f3stico mais comum entre esse grupo foi de obstru\u00e7\u00e3o intestinal. Al\u00e9m disso, 59% deles foram diagnosticados com alto risco nutricional logo na admiss\u00e3o. Em m\u00e9dia, todos receberam a nutri\u00e7\u00e3o parenteral por 11 dias e 54% tiveram sinais de altera\u00e7\u00f5es no n\u00edvel do f\u00f3sforo<sup>11<\/sup>.<\/p>\n<p>Por fim, outro exemplo de aten\u00e7\u00e3o com disfun\u00e7\u00f5es metab\u00f3licas associadas \u00e0 s\u00edndrome de realimenta\u00e7\u00e3o s\u00e3o os pacientes submetidos a cirurgias bari\u00e1tricas.<\/p>\n<p>Resumidamente,<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5644858\/\"> destacamos um relato de caso publicado em 2016 <\/a>que mostra como uma paciente, que havia passado pelo procedimento e usava nutri\u00e7\u00e3o parenteral, apresentou desequil\u00edbrios eletrol\u00edticos significativos<sup>1<\/sup>.<\/p>\n<p>Isso refor\u00e7a que pacientes ap\u00f3s a cirurgia bari\u00e1trica est\u00e3o sob risco da s\u00edndrome de realimenta\u00e7\u00e3o, mesmo quando ainda est\u00e3o acima do peso. Logo, protocolos para o manejo da s\u00edndrome s\u00e3o necess\u00e1rios e fundamentais para guiarem condutas que reduzam o risco para o desenvolvimento de complica\u00e7\u00f5es. Ap\u00f3s 14 dias, os n\u00edveis de fosfato voltaram ao normal e os sintomas neurol\u00f3gicos melhoraram<sup>1<\/sup>.<img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-2001\" src=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/wp-content\/uploads\/sites\/3\/2024\/09\/lam167-imagem1.png\" alt=\"\" width=\"940\" height=\"482\" srcset=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/wp-content\/uploads\/sites\/3\/2024\/09\/lam167-imagem1.png 940w, https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/wp-content\/uploads\/sites\/3\/2024\/09\/lam167-imagem1-300x154.png 300w, https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/wp-content\/uploads\/sites\/3\/2024\/09\/lam167-imagem1-768x394.png 768w, https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/wp-content\/uploads\/sites\/3\/2024\/09\/lam167-imagem1-580x297.png 580w\" sizes=\"auto, (max-width: 940px) 100vw, 940px\" \/><\/p>\n<h2>O que pode ser levado em conta para reduzir o risco desse problema?<\/h2>\n<p>Um<strong> dos marcadores utilizados para avaliar o risco de s\u00edndrome de realimenta\u00e7\u00e3o \u00e9 a mensura\u00e7\u00e3o da concentra\u00e7\u00e3o s\u00e9rica de albumina<\/strong>, ainda que tal altera\u00e7\u00e3o possa estar associada a outras comorbidades, incluindo a pr\u00f3pria desnutri\u00e7\u00e3o<sup>13<\/sup>.<\/p>\n<p>Nesse cen\u00e1rio, novos estudos v\u00eam tentando demonstrar medidas quantitativas para an\u00e1lise do risco e predi\u00e7\u00e3o da s\u00edndrome de realimenta\u00e7\u00e3o, como \u00e9 o caso de uma publica\u00e7\u00e3o de pesquisadores da Universidade Estadual de Ohio.<\/p>\n<p>Eles levantaram a hip\u00f3tese de que a an\u00e1lise da composi\u00e7\u00e3o muscular poderia predizer o risco de tal complica\u00e7\u00e3o. No<a href=\"https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/epdf\/10.1002\/jpen.1943\"> artigo<\/a>, pacientes com uma densidade muscular menor, medida via tomografia computadorizada e an\u00e1lise do m\u00fasculo psoas, apresentavam um maior comprometimento nos n\u00edveis de f\u00f3sforo no organismo e, consequentemente, risco mais elevado de desenvolver a s\u00edndrome de realimenta\u00e7\u00e3o<sup>13<\/sup>.<\/p>\n<p>Seja como for, diante da rela\u00e7\u00e3o entre hipofosfatemia e a s\u00edndrome da realimenta\u00e7\u00e3o, profissionais respons\u00e1veis pelo manejo de indiv\u00edduos recebendo terapia nutricional devem estar atentos aos<strong> fatores cl\u00e1ssicos de riscos, as medidas essenciais para diminuir a chance do problema <\/strong>(come\u00e7ando com aporte cal\u00f3rico reduzido no in\u00edcio da reintrodu\u00e7\u00e3o da nutri\u00e7\u00e3o, por exemplo) <strong>e o monitoramento apropriado ao longo de toda a jornada do paciente<sup>6<\/sup>.<\/strong><\/p>\n<p>Aproveite e continue navegando no <a href=\"https:\/\/lam.unitedforclinicalnutrition.com\/pt-br\/\">Unidos Pela Nutri\u00e7\u00e3o Cl\u00ednica,<\/a> onde voc\u00ea encontra mais conte\u00fados cuidadosamente desenvolvidos sobre a desnutri\u00e7\u00e3o associada \u00e0 doen\u00e7as.<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p>Refer\u00eancias<\/p>\n<ol>\n<li>Chiappetta S, Stein J. Refeeding Syndrome: An Important Complication Following Obesity Surgery. Obes Facts. 2016;9(1):12-6. 5624. Dispon\u00edvel em: &lt;<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5644858\/\">https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC5644858\/<\/a>&gt; Acesso em 10 de abril de 2024.<\/li>\n<li>van Zanten AR. Changing paradigms in metabolic support and nutrition therapy during critical illness. Curr Opin Crit Care. 2018;24(4):223-227. Dispon\u00edvel em: &lt;<a href=\"https:\/\/journals.lww.com\/co-criticalcare\/abstract\/2018\/08000\/changing_paradigms_in_metabolic_support_and.2.aspx\">https:\/\/journals.lww.com\/co-criticalcare\/abstract\/2018\/08000\/changing_paradigms_in_metabolic_support_and.2.aspx<\/a>&gt; Acesso em 14 de mar\u00e7o de 2024.<\/li>\n<li>Gaasbeek A, Meinders AE. Hypophosphatemia: an update on its etiology and treatment. Am J Med. 2005;118(10):1094e101. Dispon\u00edvel em: &lt;<a href=\"https:\/\/www.amjmed.com\/article\/S0002-9343(05)00100-2\/abstract\">https:\/\/www.amjmed.com\/article\/S0002-9343(05)00100-2\/abstract<\/a>&gt; Acesso em 14 de mar\u00e7o de 2024.<\/li>\n<li>Levi M. Post-transplant hypophosphatemia. Kidney Int. 2001;59:2377\u20132387. Dispon\u00edvel em: &lt; <a href=\"https:\/\/www.kidney-international.org\/article\/S0085-2538(15)47745-2\/pdf\">https:\/\/www.kidney-international.org\/article\/S0085-2538(15)47745-2\/pdf<\/a>&gt; Acesso em 02 de maio de 2024.<\/li>\n<li>Reintam Blaser A, Gunst J, Ichai C, Casaer MP, Benstoem C, Besch G, et al. Hypophosphatemia in critically ill adults and children &#8211; a systematic review. Clin Nutr. 2021;40(4):1744e54. Dispon\u00edvel em: &lt;<a href=\"https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(20)30517-3\/abstract\">https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(20)30517-3\/abstract<\/a>&gt; Acesso em 14 de mar\u00e7o de 2024.<\/li>\n<li>Mehanna HM, Moledina J, Travis J. Refeeding syndrome: what it is, and how to prevent and treat it. 2008;336(7659):1495e8. Dispon\u00edvel em: &lt;<a href=\"https:\/\/www.bmj.com\/content\/336\/7659\/1495.long\">https:\/\/www.bmj.com\/content\/336\/7659\/1495.long<\/a>&gt; Acesso em 14 de mar\u00e7o de 2024.<\/li>\n<li>Veldscholte K, Veen MAN, Eveleens RD, de Jonge RCJ, Vanhorebeek I, Gunst J, et al. Early hypophosphatemia in critically ill children and the effect of parenteral nutrition: A secondary analysis of the PEPaNIC RCT. Clin Nutr. 2022;41(11):2500-2508. Dispon\u00edvel em: &lt;<a href=\"https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(22)00326-0\/fulltext\">https:\/\/www.clinicalnutritionjournal.com\/article\/S0261-5614(22)00326-0\/fulltext<\/a>&gt; Acesso em 10 de abril de 2024.<\/li>\n<li>Fuentebella J, Kerner JA. Refeeding syndrome. Pediatr Clin. 2009;56(5):1201e10. Dispon\u00edvel em: &lt;<a href=\"https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S0031395509000832?via%3Dihub\">https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S0031395509000832?via%3Dihub<\/a>&gt; Acesso em 14 de mar\u00e7o de 2024.<\/li>\n<li>Skipper A. Refeeding syndrome or refeeding hypophosphatemia: a systematic review of cases. Nutr Clin Pract. 2012;27(1):34-40. Dispon\u00edvel em: &lt;<a href=\"https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/10.1177\/0884533611427916\">https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/10.1177\/0884533611427916<\/a>&gt; Acesso em 14 de mar\u00e7o de 2024.<\/li>\n<li>Bradford CV, Cober MP, Miller JL. Refeeding syndrome in the neonatal intensive care unit. J Pediatr Pharmacol Ther. 2021;26(8):771-782. Dispon\u00edvel em: &lt;<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC8591996\/\">https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC8591996\/<\/a>&gt; Acesso em 10 de abril de 2024.<\/li>\n<li>Ashmore D, Lee M, Nutrition in Emergency Surgery (NEmS) collaborative, Ball W, Blanshard L, Craig A, et al. Parental nutrition in emergency surgery: A multicentre cross\u2010sectional study. J Hum Nutr Diet. 2022;35(1):5-13. Dispon\u00edvel em: &lt;<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/33829582\/\">https:\/\/pubmed.ncbi.nlm.nih.gov\/33829582\/<\/a>&gt; Acesso em 10 de abril de 2024.<\/li>\n<li>Crook MA, Hally V, Panteli JV. The importance of the refeeding syndrome. 2001 Jul-Aug;17(7-8):632-7. Dispon\u00edvel em: &lt;<a href=\"https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S0899900701005421?via%3Dihub\">https:\/\/www.sciencedirect.com\/science\/article\/abs\/pii\/S0899900701005421?via%3Dihub<\/a>&gt; Acesso em 14 de mar\u00e7o de 2024.<\/li>\n<li>Ireland M, Lo W, Villarreal M, Coleman L, Schubauer K, Strassels S, et al. Computed Tomography\u2013Measured Psoas Muscle Density as a Predictive Factor for Hypophosphatemia Associated With Refeeding. J Parenter Enteral Nutr. 2021;45(4):800-809. Dispon\u00edvel em: &lt;<a href=\"https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/10.1002\/jpen.1943\">https:\/\/aspenjournals.onlinelibrary.wiley.com\/doi\/10.1002\/jpen.1943<\/a>&gt; Acesso em 14 de mar\u00e7o de 2024.<\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>A rela\u00e7\u00e3o entre hipofosfatemia e a s\u00edndrome da realimenta\u00e7\u00e3o deve sempre ser considerada ao abordarmos um paciente que ficou muito tempo em jejum, recebendo baixo aporte nutricional ou mesmo desnutrido, uma vez que a reintrodu\u00e7\u00e3o da alimenta\u00e7\u00e3o (inclusive por via enteral ou parenteral) est\u00e1 frequentemente associada a essas complica\u00e7\u00f5es1. Logo, vale entender melhor quais mecanismos [&hellip;]<\/p>\n","protected":false},"author":5902,"featured_media":2003,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[43],"tags":[70,220,76,67,88],"class_list":["post-2000","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-artigo-2","tag-desnutricao","tag-fosforo","tag-nutricao-enteral","tag-nutricao-parenteral","tag-sindrome-de-realimentacao"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Saiba mais sobre a hipofosfatemia e a s\u00edndrome da realimenta\u00e7\u00e3o<\/title>\n<meta name=\"description\" content=\"A hipofosfatemia e a s\u00edndrome da realimenta\u00e7\u00e3o atingem pacientes recebendo nutri\u00e7\u00e3o enteral ou parenteral e podem ter consequ\u00eancias graves.\" \/>\n<meta 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