Case Study #3: Renal Disease 1. Please be concise and use only the space provided. 2. Please cite sources as necessary.

Transcription

1 NUT 116BL Winter 2013 Name: Cammane Wun Section: A02 Case Study #3: Renal Disease 50 points 1. Please be concise and use only the space provided. 2. Please cite sources as necessary. 3. You may use your textbook, the pocket resource, and drugs.com Part I: Initial Presentation Chief Complaint: progressive anorexia with N/V, 5 kg weight gain in the past 10 days, edema, fatigue, worsening SOB with 2 pillow orthopnea, pruritus, and inability to urinate. Patient History: BK is a 42-year-old female. She was diagnosed with type 2 DM at age 12 but has had poor adherence to treatment recommendations. She lives with her husband and children. Her husband also has type 2 diabetes. Her kidney function has been declining for the last 5 years with anemia, decreased GFR, and increased creatinine, phosphate and urea. BK is being admitted in preparations for kidney replacement therapy. Onset: Dx: CKD 3 two years ago. Acute symptoms x 10 days Tx: prepare for kidney replacement therapy and nutrition consult PMH: Gravida 3/para 2. Both infants weighed more than 11 lbs Meds: Lasix, Metformin, Vasotec (has not refilled Vasotec prescription, inconsistent Metformin and Lasix use) Family hx: Mother, sister and two brothers have type 2 DM Physical Exam: General appearance: Overweight female, appears older than her age. Lethargic, c/o N/V Vitals: Temp 98.6 F, BP 220/80 mm Hg, HR. 86 BPM, RR 25 Extremities: muscle weakness, 3+ pitting edema Chest/lungs: Rhonchi with rales Ht: 5 2 wt: 158 lbs. Nutrition History: General: Reports appetite is usually good but has been reduced recently because of the N/V. Attended a 4 week course through the hospital 8 years ago to learn type 2 DM management, but said she is so busy with her family that she doesn t have time to plan her meals. Usual dietary intake Breakfast: 2 eggs, 3-corn tortilla, ham or bacon. 8 oz. Tampico Morning snack: 4 orange juice, banana Lunch: 1 cup homemade chicken soup, 2 quesadillas 12 oz. Tampico Afternoon snack: 12 oz apple juice, 4 cookies Dinner: 6 oz. Rice, 6 oz. beans, 2 oz. cheese, 2 oz. salsa, 4 oz. chicken, 4 corn tortillas 8 oz. whole milk Evening Snack: 8 oz. ice cream Food allergy/intolerance- NKFA Dx: Chronic kidney disease; hypertension; type 2 DM; hyperlipidemia

2 Tx Plan: Renal diet 2 gm sodium, 2 gm potassium, and 1 gm phosphorus diet 1.5 L fluid restriction. CBC, blood chemistry Vitamin/mineral supplement Metformin, Lasix, Vasotec, Phos Lo, Sodium Bicarbonate, EPO, Iron Laboratory: Lab Value Interpretation GFR 15 ml/min BUN 90 mg/dl Serum creatinine 14 mg/dl Creatinine clearance 17.0 ml/min Serum sodium 142 meq/l WNL Serum potassium 5.7 meq/l Serum albumin 2.8 g/dl Hgb /Hct 11.5 g/dl/28% Serum transferrin 155 mg/dl BP 160/100, standing, right arm Urine ph 7.31 WNL Serum phosphorus 5.0 mg/dl WNL (borderline) PTH 100 pg/ml Urine volume 450-mL/24 h 1. In the table of laboratory values above, for the column labeled Interpretation, indicate whether the values are high ( ), low ( ), or within normal limits (wnl). (7 points) 2. Briefly explain how type 2 DM can lead to chronic kidney disease. (3 points) When blood sugar is left uncontrolled, the kidneys have to work harder to deal with the extra glucose. The glomerulus starts to thicken and allow more protein to leak into the urine. More glomeruli are destroyed, putting a heavier load on the remaining functioning nephrons. The kidneys are able to compensate for the damaged glomeruli in the beginning. But eventually, enough glomeruli become destroyed so that the kidneys can no longer function at normal levels. (NTP p.527) 3. Although BK c/o anorexia and weight loss, today s weight shows that she has actually gained weight. Explain this discrepancy in subjective versus objective information. (1 point) BK's weight reflects a weight gain because she has edema. Her GFR and urine production are low, so her body is unable to remove excess fluids.

3 4. Which foods in her usual diet are contributing most to: (2 points) a) Phosphorous levels: Quesadilla (cheese), milk, ice cream, beans, Tampico (punch), and corn tortillas b) Potassium levels: Quesadilla (cheese), milk, ice cream, beans, orange juice, banana, and salsa. 5. Explain the rationale for the following interventions: (4 points) a) Phosphate binder Phosphate binders bind to phosphate to prevent it from entering the blood stream. This helps to lower serum phosphate. b) Calcium supplement During renal disease, the kidneys are unable to activate Vitamin D. Vitamin D is related to Ca absorption from food, so less calcium is absorbed. Renal disease pts also tend to have increased the levels of PTH, which moves Ca out of the bones and increasing Ca requirements for our pt. Another rationale for a Ca supplement is that many foods that are high in phosphorous are also high in Ca. c) Iron and EPO The kidneys are responsible for the production of EPO. In renal disease, the kidneys cannot make enough EPO to produce adequate red blood cells. Iron is included because it is an important component of healthy red blood cells. d) Vitamin supplement containing only water soluble vitamin Fat soluble vitamins can be stored in the body and can build up to toxic levels. Water soluble vitamins are not stored in the body and so must be obtained through intake. 6. Explain the purpose of each of the following interventions, and list the data (laboratory parameters, symptoms, etc.) indicating the need for treatment. (8 points) - a) Protein restriction The kidneys have a decreased ability for the excretion of the products that result from protein metabolism. If too much protein is consumed, these products build up and are toxic to the body. Monitor BUN and UUN. b) Phosphorus restriction The kidneys have a decreased ability to regulate phosphorus. If serum phosphorus goes up, it causes PTH to be produced. PTH pulls phosphorus and Ca from the bones into the blood stream. The circulating phosphorus and Ca can then result in the mineralization of soft tissue. Monitor serum phosphorus. c) Potassium restriction The kidneys have a decreased ability to regulate potassium. If serum potassium increases too much, it can result in irregular heartbeats. Monitor serum K. d) Fluid and/or sodium restriction The kidneys have a decreased ability to regulate Na. JIncreased Na pulls water with it, so an individual will experience the accumulation of extra fluid. The kidneys are also unable to excrete the excess fluid so edema and high blood pressure can result. Monitor serum Na, BP, and physical signs of edema.

4 7. Complete an ADIME note for BK at this point in time (12 points) including the Renal Diet Pattern for BK to use after she returns home and begins regular dialysis treatment. Create an appropriate and a well-balanced Renal Diet for her to follow using the attached renal diet pattern document. (8 points) A: 42yo female. C/o anorexia, N/V, 5kg wt gain in past 10 days, edema, fatigue, worsening SOB with 2 pillow orthopnea, pruritus, inability to urinate. Family hx of Type 2 DM. Ht: 5'2" CW: 71.8kg Edema-Free BW: 66.8kg Adjusted BW: 65.4kg IBW: 50kg % IBW: 143.6% BMI: 29.0 PMH: Type 2 DM diagnosis at 12yo. Gravida 3/para 2. Both infants >11#. Kidney fxn declining for past 5yrs with anemia, decreased GFR, and increased creatinine, phosphate, and urea. Dx: CKD 3 two yrs ago. Acute symptoms x 10 days. Tx: Kidney replacement. Physical Examination: Appears older than age, lethargic. Muscle weakness, 3+ pitting edema. Chest/lungs: rhonchi with rales. Medication: Lasix, Metformin, Vasotec (inconsistent use) Lab Values: GRF: 15mL/min - Low BUN: 90mg/dL - High Serum Creatinine: 14mg/dL - High Creatinine Clearance: 17.0mL/min - Low Serum Sodium: 142mEq/L - WNL Serum Potassium: 5.7mEq/L - High Serum Albumin: 2.8g/dL - Low 24 Hr Recall: Kcal: 4081 kcal Protein: 184 gm Na: 6473 mg K: 4263 mg Phosphorous: 3142 mg Ca: 2351 mg Fluids: ml Requirements: (pre-op) Kcal: 1773 to 1900 kcal Protein: 39 to 49gm Fluids: 1962mL Hgb: 11.5g/dL - Low Hct: 28% - Low Serum Transferrin: 155mg/dL - Low BP: 160/100 - High Serum Phosphorous: 5.0mg/dL - WNL (borderline high) PTH: 100pg/mL - High Urine Volume: 450-mL/24hr - Low D: Undesirable food choices (NB 1.7) r/t reported lack of time AEB dietary recall of 4081kcal, 184gm protein, 6473mg Na, 4263mg K, and 3142mg P. I: Recommendations: 1. Encourage intake of kcal and 39-49gm protein. 2. Encourage restriction of 2gm sodium, 2gm potassium, and 1gm phosphorous. 3. Encourage intake of a multi-mineral, multi-vitamin supplement. 4. Encourage consistent medication intake. 5. Post-Op: 1. Encourage adherence to provided Renal Diet Pattern with restriction of 2gm sodium, 2gm potassium, and 1gm phosphorous. Encourage intake of kcal, 85-98gm protein, and restriction to 1.5L fluids. 2. Goals 1. Pt will have an intake of kcal, 85-98gm protein, and restriction to 1.5L fluids by 1 month post-op. 2. Pt will have an intake below 2gm sodium, 2gm potassium, and 1gm phosphorous by 1 month post-op. ME: Follow up visit 1 month post-op. Monitor albumin, BUN, serum calcium, creatinine, hematocrit, hemoglobin, triglycerides, serum phosphorous, serum potassium, and intact PTH. Monitor physical signs of edema. Monitor dietary intake through 24hr recall. Monitor medication intake. Cammane Wun, RD 12:10PM Feb 28, 2013

5 CW: 158# x (2.2kg/#) = 71.8 kg Height: 62 inches x (2.54cm/inch) = cm x (1m/100cm) = 1.57m BMI: 71.8kg / (1.57m) 2 = 29.1 Edema-Free BW: 71.8kg 5kg = 66.8kg IBW: Hamwi Equation (PR online p.19) 100# + 2(5#) 110# x (2.2kg/#) = 50kg % IBW: (71.8kg / 50kg) x 100 = 143.6% Adjusted BW: NTP p kg + [(61kg 66.8kg) x 0.25] [-5.8kg x 0.25] [-1.45] = 65.4kg Kcal Requirement: Mifflin-St. Jeor (PR p. 6) Explanation: ADA rates the evidence for the use of Mifflin-St. Jeo as Strong, Conditional. Adjusted BW was used because pt has edema. IBW was not used because pt is 143.6% of IBW. RMR: (9.99 x 65.4kg) + (6.25 x cm) (5 x 42yo) = kcal EER: x 1.4 to 1.5 x 1 = to kcal Explanation: AF of 1.4 to 1.5 was chosen because pt reports that she is so busy with her family that she doesn t [even] have time to plan her meals. IF of 1.0 was chosen because individual has no special energy requirements pre-op. A new post-op kcal requirement was not calculated with the assumption that no complications occurred with pt s transplant. Protein Requirement: NTP p to 0.74 gm/kg x 65.4kg = to gm/day Post-Op Protein Requirement: NTP p to 1.5 gm/kg x 65.4kg = to 98.1 gm/day

6 Follow up visit 1 month later Feb 25 Feb 27 BUN, mg/dl Body wt, kg UUN, g/24 hr BK has been on HD for a month now. At her dialysis visit with you the RD, she tells you that she has been noticing that her weight has been fluctuating. What can you tell her about potential weight changes in-between HD sessions? (2 points) Since pt's urine production is low, she gains weight from consuming fluids between her HD sessions. Then during her HD sessions, fluids are removed so that she will have lost weight by the end of the session. 9. You interview BK at some length. She assures you that she is following her diet. Based on her UUN, is she consuming the amount of protein you recommended on her diet pattern? Show calculations to back up your conclusion. (3 points) NTP p.54 0 = (intake / 6.25) = intake / 6.25 = No, pt is not consuming the recommended post-op amount of protein. 10. The patient tells you she sometimes uses a salt substitute. Is this appropriate and why or why not? (1 point) Salt substitutes are usually made with potassium, which she needs to be restricting in her diet. Because of this, salt substitutes are inappropriate unless she decreases her potassium intake from other parts of her diet.