The Kidney Disease Outcomes Quality Initiative Clinical Practice Guidelines for Nutrition in Chronic Kidney Disease: 2020 Update recommends adjusting dietary phosphorus to maintain a serum phosphate goal for hemodialysis patients in the normal range (0.81 to 1.45 mmol/L [2.5 to 4.5 mg/dL]). This is lower than the serum phosphate goal used by many dialysis centers (0.97 to 1.78 mmol/L [3.0 and 5.5 mg/dL]). Although context and clinical judgment must always be considered when providing individualized care to patients, a guideline implementation study conducted from December 2020 to December 2022 found that, based on their documentation, registered dietitian nutritionists from two national dialysis chains are almost universally using dialysis center goals instead of the lower phosphate goal recommended by the guideline. This commentary discusses the possible barriers to implementing the Kidney Disease Outcomes Quality Initiative 2020 nutrition guideline\'s phosphorus recommendation and proposes a systems level approach to promote and support adoption of the recommendation. Calls to action for potential changes in clinician practices, organizational/institutional culture, and government regulations are put forth.

The objective of this study was to evaluate the effect of a novel consensus bacterial 6-phytase variant (PhyG) on egg productivity, eggshell quality, and body composition of laying hens fed inorganic phosphate-free diets with reduced energy and nutrients from 23 to 72 wk of age. Five treatments were randomly assigned, performing 28 replicates per treatment with 4 hens each, totaling 560 Hy-Line W80 birds. A positive control (PC) feed was formulated to contain adequate levels of energy and nutrients. A negative control (NC) feed was formulated without added inorganic phosphate (0.12% nonphytic phosphorus [nPP]) and reduced in Ca, Na, dig AA, and metabolizable energy in comparison with PC feed. Phytase was supplemented in the NC feed at 0, 300, 600, and 900 FTU/kg of feed. The responses evaluated were performance, egg quality, economic analysis, body composition, and tibia composition. Data were analyzed by a 2-factor (diet and age) repeated measure analysis. Overall, the feed intake, hen-day egg production, egg mass, and egg revenue were reduced by the complete removal of dicalcium phosphate (DCP) (P < 0.05). Supplement phytase in the NC diet elicits a positive response on each one of those variables. Laying hens consuming the NC feed with 900 FTU/kg of phytase produced more eggs per hen-housed compared with the phytase dosages of 300 and 600 FTU/kg. Body composition was not affected by dietary nPP, Ca, Na, dig AA, and energy reductions (P > 0.05). At 72-wk-old, tibia ash was reduced in hens consuming the NC diet vs. PC (P < 0.05) and no difference was observed between hens supplemented with phytase and the PC feed. Margin over feeding cost increased in a dose-dependent manner with phytase supplementation. Supplementation with 900 FTU/kg of phytase is recommended to improve the number of eggs produced per hen-housed and the number of marketable eggs produced through 23 to 72 wk of age, under this dietary setting.

UNASSIGNED: Chronic kidney disease (CKD): abnormalities of kidney structure or function, present for over 3 months. Staging of CKD is based on GFR and albuminuria (not graded). Osteoporosis: compromised bone strength (low bone mass, disturbance of microarchitecture) predisposing to fracture. By definition, osteoporosis is diagnosed if the bone mineral density T‑score is ≤ -2.5. Furthermore, osteoporosis is diagnosed if a low-trauma (inadequate trauma) fracture occurs, irrespective of the measured T‑score (not graded). The prevalence of osteoporosis, osteoporotic fractures and CKD is increasing worldwide (not graded). PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENT OF CHRONIC KIDNEY DISEASE-MINERAL AND BONE DISORDER (CKD-MBD): Definition of CKD-MBD: a systemic disorder of mineral and bone metabolism due to CKD manifested by either one or a combination of the following: abnormalities of calcium, phosphorus, PTH, or vitamin D metabolism; renal osteodystrophy; vascular calcification (not graded). Increased, normal or decreased bone turnover can be found in renal osteodystrophy (not graded). Depending on CKD stage, routine monitoring of calcium, phosphorus, alkaline phosphatase, PTH and 25-OH-vitamin D is recommended (2C). Recommendations for treatment of CKD-MBD: Avoid hypercalcemia (1C). In cases of hyperphosphatemia, lower phosphorus towards normal range (2C). Keep PTH within or slightly above normal range (2D). Vitamin D deficiency should be avoided and treated when diagnosed (1C).
UNASSIGNED: Densitometry (using dual X‑ray absorptiometry, DXA): low T‑score correlates with increased fracture risk across all stages of CKD (not graded). A decrease of the T‑score by 1 unit approximately doubles the risk for osteoporotic fracture (not graded). A T-score ≥ -2.5 does not exclude osteoporosis (not graded). Bone mineral density of the lumbar spine measured by DXA can be increased and therefore should not be used for the diagnosis or monitoring of osteoporosis in the presence of aortic calcification, osteophytes or vertebral fracture (not graded). FRAX can be used to aid fracture risk estimation in all stages of CKD (1C). Bone turnover markers can be measured in individual cases to monitor treatment (2D). Bone biopsy may be considered in individual cases, especially in patients with CKD G5 (eGFR < 15 ml/min/1.73 m2) or CKD 5D (dialysis).
UNASSIGNED: Hypocalcemia should be treated and serum calcium normalized before initiating osteoporosis therapy (1C). CKD G1-G2 (eGFR ≥ 60 ml/min/1.73 m2): treat osteoporosis as recommended for the general population (1A). CKD G3-G5D (eGFR < 60 ml/min/1.73 m2 to dialysis): treat CKD-MBD first before initiating osteoporosis treatment (2C). CKD G3 (eGFR 30-59 ml/min/1.73 m2) with PTH within normal limits and osteoporotic fracture and/or high fracture risk according to FRAX: treat osteoporosis as recommended for the general population (2B). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) with osteoporotic fracture (secondary prevention): Individualized treatment of osteoporosis is recommended (2C). CKD G4-5 (eGFR < 30 ml/min/1.73 m2) and high fracture risk (e.g. FRAX score > 20% for a major osteoporotic fracture or > 5% for hip fracture) but without prevalent osteoporotic fracture (primary prevention): treatment of osteoporosis may be considered and initiated individually (2D). CKD G4-5D (eGFR < 30 ml/min/1.73 m2 to dialysis): Calcium should be measured 1-2 weeks after initiation of antiresorptive therapy (1C).
UNASSIGNED: Resistance training prioritizing major muscle groups thrice weekly (1B). Aerobic exercise training for 40 min four times per week (1B). Coordination and balance exercises thrice weekly (1B). Flexibility exercise 3-7 times per week (1B).
UNASSIGNED: DEFINITION UND EPIDEMIOLOGIE: Chronische Niereninsuffizienz („chronic kidney disease“ [CKD]): Abnormität der Nierenstruktur oder Nierenfunktion für länger als 3 Monate. Stadieneinteilung der CKD anhand GFR und Albuminurie (not graded). Osteoporose: Erkrankung des Skeletts (verminderte Knochenmasse, Störung der Mikroarchitektur) mit erhöhtem Knochenbruchrisiko. Bei einem T‑Score ≤ −2,5 liegt definitionsgemäß eine Osteoporose vor. Bei Auftreten einer Fraktur nach inadäquatem Trauma liegt, unabhängig vom T‑Score, eine manifeste Osteoporose vor (not graded). Die Prävalenz von Osteoporose und osteoporotischen Frakturen sowie die CKD nehmen weltweit zu (not graded). PATHOPHYSIOLOGIE, DIAGNOSTIK UND THERAPIE DER CHRONIC KIDNEY DISEASE – MINERAL AND BONE DISORDER (CKD-MBD): Definition des CKD-MBD-Syndroms: Störung des Kalzium‑, Phosphat‑, Vitamin-D- und Parathormon(PTH)-Haushalts sowie renale Osteodystrophie und vaskuläre Kalzifikation (not graded). Knochenstoffwechsel bei renaler Osteodystrophie: gesteigerter, normaler oder verminderter Knochenumbau möglich (not graded). Regelmäßige Laborkontrollen von Kalzium, Phosphat, alkalischer Phosphatase, PTH und 25-OH-Vitamin D mit Kontrollintervall je nach CKD-Stadium werden empfohlen (2C). Therapieziele bei CKD-MBD: Hyperkalzämie vermeiden (1C) Erhöhtes Phosphat in Richtung Normalbereich senken (2C) PTH im Normbereich bis leicht erhöht halten (2D) Vitamin-D-Mangel vermeiden bzw. beheben (1C) DIAGNOSTIK UND RISIKOSTRATIFIZIERUNG DER OSTEOPOROSE BEI CKD: Densitometrie (mittels Dual Energy X‑ray Absorptiometry [DXA]): Niedriger T‑Score korreliert in allen Stadien der CKD mit höherem Frakturrisiko (not graded). Verdopplung des Frakturrisikos pro Abnahme des T‑Scores um 1 Einheit (not graded). T‑Score > −2,5 schließt eine Osteoporose nicht aus (not graded). Falsch-hohe LWS-KMD-Messergebnisse können unter anderem bei aortaler Verkalkung, degenerativen Wirbelsäulenveränderungen (Osteophyten) oder bei bereits eingebrochenen Wirbelkörpern vorkommen (not graded). FRAX: Anwendung in allen CKD-Stadien orientierend möglich (1C). Knochenstoffwechselmarker: Bestimmung in Einzelfällen zum Therapiemonitoring (2D). Knochenbiopsie: In Einzelfällen, insbesondere bei CKD G5 (eGFR < 15 ml/min/1,73 m2) und CKD G5D (Dialyse) erwägen (2D).
UNASSIGNED: Hypokalziämie vor Einleitung einer spezifischen Osteoporosetherapie ausgleichen (1C) Bei CKD G1–G2 (eGFR ≥ 60 ml/min/1,73 m2): Behandlung der Osteoporose wie für die Allgemeinbevölkerung empfohlen (1A). Bei CKD G3–G5D (eGFR < 60 ml/min/1,73 m2 bis Dialysestadium): primär Behandlung der laborchemischen Zeichen einer CKD-MBD (2C). Bei CKD G3 (eGFR 30–59 ml/min/1,73 m2) mit PTH im Normbereich und osteoporotischer Fraktur und/oder hohem Frakturrisiko gemäß FRAX: Behandlung der Osteoporose wie für die Allgemeinbevölkerung empfohlen (2B). Bei CKD G4–5 (eGFR < 30 ml/min/1,73 m2) und osteoporotischer Fraktur (Sekundärprävention): Osteoporosetherapie individualisiert empfohlen (2C). Bei CKD G4–5 (eGFR < 30 ml/min/1,73 m2) mit hohem Frakturrisiko (z. B. FRAX-score > 20 % für eine „major osteoporotic fracture“ oder > 5 % für eine Hüftfraktur) ohne osteoporotische Fraktur (Primärprävention): Osteoporosetherapie erwägen und ggf. auch einleiten (2D). Antiresorptive Behandlung bei CKD G4–5 (eGFR < 30 ml/min/1,73 m2): Kalziumkontrolle 1 bis 2 Wochen nach Therapiebeginn (1C). PHYSIKALISCH-REHABILITATIVE MAßNAHMEN: Krafttraining großer Muskelgruppen dreimal wöchentlich (1B). Ausdauertraining viermal wöchentlich 40 min (1B). Koordinationstraining/Balanceübungen dreimal wöchentlich (1B). Beweglichkeitsübungen drei- bis siebenmal wöchentlich (1B).

The effect of a novel consensus bacterial 6-phytase variant (PhyG) on total tract digestibility (ATTD) of minerals and bone ash was evaluated in pigs fed diets containing medium- and high-solubility limestone (MSL and HSL, 69.6 and 91.7% solubility, respectively, at 5 min, pH 3.0) in a randomized complete block design. For each limestone, eight diets were formulated: an inorganic phosphate-free negative control (NC) based on wheat, corn, soybean-meal, canola-meal and rice-barn [0.18% standardized total tract digestible (STTD) P and 0.59% Ca]; the NC supplemented with 250, 500, 1,000, or 2,000 FTU/kg of PhyG, and; the NC with added monocalcium phosphate (MCP) and limestone to produce three positive controls (0.33, 0.27, and 0.21% STTD P, and 0.75, 0.70, and 0.64% Ca, respectively; PC1, PC2, PC3). In total, 128 pigs (12.8 ± 1.33 kg, 8 pigs/treatment, housed individually) were adapted for 16 d followed by 4 d of fecal collection. Femurs were collected from euthanized pigs on day 21. Data were analyzed by one-way ANOVA with means separation by Tukey\'s test, and by factorial analysis (2 x 4: 2 levels of limestone solubility, 4 STTD P levels, and 2 × 5: 2 levels of limestone solubility, 5 PhyG dose levels). Phytase dose-response was analyzed by curve fitting. A consistent negative effect of HSL on ATTD P and Ca was observed in control diets (P < 0.001). Across phytase-supplemented diets, HSL reduced (P < 0.05) ATTD Ca and P (% and g/kg) compared with MSL. Across limestones, increasing phytase dose level increased (P < 0.05) ATTD P exponentially. Limestone solubility had no effect on bone ash, but PhyG linearly increased (P < 0.05) bone ash; 500 FTU/kg or higher maintained bone ash (g/femur) equivalent to PC1. In conclusion, ATTD P and Ca were reduced by a high compared with a medium soluble limestone, but the novel phytase improved ATTD P and Ca independent of limestone solubility.
Microbial phytase is added to commercial pig diets to increase phosphorus (P) availability and reduce P excretion. It is known that an excess of calcium (Ca), mostly sourced from limestone, can affect phytase efficacy. However, less is known about the impact of limestone quality. This study investigated the effect of a medium- compared to a high-soluble limestone (MSL and HSL, respectively), in combination with increasing dose levels of a novel phytase (PhyG), on mineral digestibility and bone mineralization in young pigs. Without phytase, total tract digestibility of P was lower with HSL than MSL, indicating a negative effect of more soluble limestone on mineral digestibility. Increasing the phytase dose increased digestibility of P with either limestone, and reduced the negative effect of HSL at high dose. Bone mineralization was unaffected by limestone but markedly increased by phytase. At 1,000 FTU/kg, PhyG released an estimated 1.89 or 2.32 g/kg of digestible P from monocalcium phosphate in diets containing MSL and HSL, respectively based on bone ash content. The results demonstrate the efficacy of PhyG in young pig diets whilst indicating that limestone solubility can affect phytase efficacy.

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.
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.
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).
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.

The effect of a novel consensus bacterial 6-phytase variant (PhyG) on apparent ileal digestibility (AID) of amino acids (AA) and phosphorus (P) utilization in young broilers when added to diets with high phytate-P (PP) content without added inorganic phosphate (Pi) and deficient in digestible (dig) AA and metabolizable energy (ME) was investigated. A total of 256 Ross 308 male broilers were assigned to 4 treatments (8 birds/cage, 8 cages/treatment) in a completely randomized design. Treatments comprised a positive control (PC, 2,975 kcal/kg ME, 3.7 g/kg dig P, 2.83 g/kg PP, 8.4 g/kg Ca, 10.6 g/kg dig lysine), a negative control (NC) without added Pi (ME -68 kcal/kg, crude protein -10 g/kg, dig AA -0.1 to -0.4 g/kg, Ca -2.0 g/kg, dig P -2.2 g/kg, Na -0.4 g/kg vs. PC), and NC plus 500 or 1,000 FTU/kg of PhyG. Test diets were corn/soy/rapeseed-meal/rice-bran-based and fed from 5 to 15 d of age. Ileal digesta and tibias were collected on day 15. Excreta was collected during days 12 to 15 to determine P retention. The NC (vs. PC) reduced (P < 0.05) P retention (-10.4% units), tibia ash (-14.3% units), weight gain (-109 g), feed intake (-82 g) and increased FCR (from 1.199 to 1.504), confirming that the NC was extremely deficient in nutrients and energy. Phytase addition to the NC linearly (P < 0.001) improved performance, but did not fully recover it to the level of the PC due to the severe nutrients/energy reduction in NC. Phytase linearly increased P retention (P < 0.001), tibia ash (P < 0.001), AID of dry matter (P < 0.05), nitrogen (P < 0.01), gross energy (P < 0.05), and all 17 individual AA (P < 0.01). At 1,000 FTU/kg, phytase increased (P < 0.05) P retention vs. PC and NC (+14.5 and +24.9% units, respectively) and increased tibia ash vs. NC (+13.8% units), equivalent to PC. The NC decreased AID of Cys, Gly, Thr, and Met vs. PC (P < 0.05). At 1,000 FTU/kg, phytase increased AID of all 17 AA vs. NC (P < 0.01), equivalent to PC. At 1,000 FTU/kg, AID AA responses (above NC) ranged from +4.5% (Met) to +15.0% (Cys), being maximal for essential Thr (+10.4%) and Val (+8.2%) and non-essential Cys (+15.0%) and Gly (+10.4%). The results highlight the efficacy of PhyG at a dose level of 500 to 1,000 FTU/kg in young broilers for improving the ileal digestibility of nitrogen, AA, and energy alongside P retention and tibia ash. The performance data emphasize the need to consider digestible nutrient intake as a response variable in exogenous enzyme studies.
Microbial phytase is widely used in commercial broiler diets to improve digestion of phosphorus (P) and reduce its excretion into the environment. Phytase improves the digestion of phosphorus and other nutrients including amino acids (AA). This study evaluated the effect of a novel consensus bacterial 6-phytase variant (PhyG) added to a nutrient-reduced diet without any added inorganic P on the digestibility of nutrients including P and AA in the ileum of young broilers. Effects on P retention and bone mineralization were also assessed. Compared to an unsupplemented negative control diet, PhyG improved growth performance, P retention, bone mineralization (tibia ash), digestibility of dry matter, nitrogen, gross energy, and all 17 individual AA during 5 to 15 d post-hatch, in a dose-dependent manner (dose range 0 to 1,000 phytase units [FTU] per kilogram of feed). For some AA, the increases in digestibility with PhyG at 1,000 FTU/kg were substantial (cysteine: +15.0%, threonine:+10.4%), and for all AA were equivalent to the responses produced by a nutritionally adequate positive control (unsupplemented) diet. The results demonstrate the efficacy of PhyG to improve AA digestibility alongside growth performance, P retention, and bone mineralization in young broilers.

To examine the association between facility-level adherence to phosphorus management guidelines and mortality among patients with haemodialysis, and to explore the facility-related factors associated with facility-level guideline adherence.
Prospective cohort study.
The Dialysis Outcomes and Practice Pattern Study, which included 57 representative dialysis facilities in Japan between 2012 and 2015.
A total of 2054 adult patients who received maintenance haemodialysis were included. We defined exposure according to the following four categories, depending on whether facility-level target ranges of serum phosphorus concentration adhered to the Japanese clinical practice guidelines: adherence group (lower limit ≥3.5 mg/dL and upper limit ≤6.0 mg/dL), low-target group (lower limit <3.5 and upper limit ≤6.0), wide-target group (lower limit <3.5 and upper limit >6.0) and high-target group (lower limit ≥3.5 and upper limit >6.0).
The primary outcome was the patient all-cause mortality rate.
The mortality rate among the patients was 7.3 per 100 person-years; 27 facilities (47%) set targets according to the guidelines. HRs for mortality with reference to the adherence group were 1.04 (95% CI 0.76 to 1.43) in the low-target group, 1.11 (95% CI 0.68 to 1.81) in the wide-target group and 1.95 (95% CI 1.12 to 3.38) in the high-target group. Involvement of dieticians in dialysis treatment was associated with facility-level guideline adherence (OR 4.51; 95% CI 1.15 to 17.7).
A higher facility-level target range for phosphorus was associated with increased patient mortality. Among facilities that set the target according to the guidelines, dieticians tended to be involved in dialysis care. These findings suggest the importance of reviewing facilities\' treatment policies in relation to updated guidelines and the need to work with relevant professionals.

A 20-d experiment was conducted to test the hypothesis that phytase increases nutrient digestibility, bone ash, and growth performance of pigs fed diets containing 0.23%, 0.29%, or 0.35% phytate-bound P. Within each level of phytate, five diets were formulated to contain 0, 500, 1,000, 2,000, or 4,000 phytase units (FTU)/kg of a novel phytase (PhyG). Three reference diets were formulated by adding a commercial Buttiauxella phytase (PhyB) at 1,000 FTU/kg to diets containing 0.23%, 0.29%, or 0.35% phytate-bound P. A randomized complete block design with 144 individually housed pigs (12.70 ± 4.01 kg), 18 diets, and 8 replicate pigs per diet was used. Pigs were adapted to diets for 15 d followed by 4 d of fecal collection. Femurs were collected on the last day of the experiment. Results indicated that diets containing 0.35% phytate-bound P had reduced (P < 0.01) digestibility of Ca, P, Mg, and K compared with diets containing less phytate-bound P. Due to increased concentration of total P in diets with high phytate, apparent total tract digestible P and bone ash were increased by PhyG to a greater extent in diets with 0.29% or 0.35% phytate-bound P than in diets with 0.23% phytate-bound P (interaction, P < 0.05). At 1,000 FTU/kg, PhyG increased P digestibility and bone P more (P < 0.05) than PhyB. The PhyG increased (P < 0.01) pig growth performance, and pigs fed diets containing 0.35% or 0.29% phytate-bound P performed better (P < 0.01) than pigs fed the 0.23% phytate-bound P diets. In conclusion, the novel phytase (i.e., PhyG) is effective in increasing bone ash, mineral digestibility, and growth performance of pigs regardless of dietary phytate level.

The capacity of a novel consensus bacterial 6-phytase variant (PhyG) to entirely replace dietary inorganic phosphorus (Pi) source in grower pigs fed diets with reduction of calcium (Ca), net energy (NE), and digestible amino acids (AA) was evaluated, using growth performance and apparent total tract digestibility (ATTD) of nutrients as outcome measures. A total of 352 mixed-sex pigs (initial BW 23.4 kg) were randomized to 4 treatments, 8 pigs/pen, and 11 pens/treatment. Diets were corn-soybean meal-based and formulated by phase (grower 1, 25 to 50 and grower 2, 50 to 75 kg BW). The positive control diet (PC) provided adequate nutrients and a negative control diet (NC) was formulated without Pi (1.2 g/kg ATTD P) and reduced in Ca (-0.12 to -0.13 percentage points), NE (-32 kcal/kg), and digestible essential AA (-0.004 to -0.026 percentage points) vs. PC. Two further treatments comprised the NC plus 500 or 1,000 FTU/kg of PhyG. Data were analyzed by ANOVA, mean contrasts and orthogonal polynomial regression. Nutrient reductions in the NC reduced (P < 0.05) average daily gain (ADG) during grower 1 and overall (73 to 136 d of age), increased (P < 0.05) feed conversion ratio (FCR) during grower 1 and overall and tended to reduce (P < 0.1) average daily feed intake (ADFI) during grower 2 and overall, vs. PC. Phytase supplementation improved (P < 0.05) FCR during grower 1, ADG during grower 2 and overall, ATTD of DM and P, and tended to improve DE (P = 0.053) in a linear dose-dependent manner. PhyG at 1,000 FTU/kg resulted in growth performance (all measures, all phases) equivalent to PC. The findings demonstrate that PhyG at 1,000 FTU/kg totally replaced Pi in complex grower pig diets containing industrial co-products, compensated a full nutrient matrix reduction and maintained performance.

BACKGROUND: In the spring of 2017, the American Society for Parenteral and Enteral Nutrition (ASPEN) Parenteral Nutrition Safety Committee and the Clinical Practice Committee convened an interprofessional task force to develop consensus recommendations for identifying patients with or at risk for refeeding syndrome (RS) and for avoiding and managing the condition. This report provides narrative review and consensus recommendations in hospitalized adult and pediatric populations.
METHODS: Because of the variation in definitions and methods reported in the literature, a consensus process was developed. Subgroups of authors investigated specific issues through literature review. Summaries were presented to the entire group for discussion via email and teleconferences. Each section was then compiled into a master document, several revisions of which were reviewed by the committee.
UNASSIGNED: This group proposes a new clinical definition, and criteria for stratifying risk with treatment and screening strategies. The authors propose that RS diagnostic criteria be stratified as follows: a decrease in any 1, 2, or 3 of serum phosphorus, potassium, and/or magnesium levels by 10%-20% (mild), 20%-30% (moderate), or >30% and/or organ dysfunction resulting from a decrease in any of these and/or due to thiamin deficiency (severe), occurring within 5 days of reintroduction of calories.
CONCLUSIONS: These consensus recommendations are intended to provide guidance regarding recognizing risk and identifying, stratifying, avoiding and managing RS. This consensus definition is additionally intended to be used as a basis for further research into the incidence, consequences, pathophysiology, avoidance, and treatment of RS.