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Refeeding syndrome (RFS) is a serious and potentially fatal complication that occurs in patients with severe malnutrition of various etiologies after repeated, uncontrolled introduction of a diet, especially carbohydrates. Complications of RFS develop due to rapid metabolic changes that occur during the switch from catabolism to anabolism, and cellular depletion of phosphorus, potassium, magnesium and micronutrients, and can affect one or more organ systems. Most of RFS complications associated with vitamin deficiency are related to thiamine deficiency. Due to its coenzyme role in the metabolism of carbohydrates and branched chain amino acids, thiamine is an important factor in maintaining the normal function primarily of cerebral energy metabolism. Understanding the basic biochemistry during starvation, and consequently the mechanisms and factors influencing metabolic changes during RFS, is important for timely identification of patients at risk and prevention of RFS and also many clinical complications it can cause regardless of nutritional support modality.