NUT 116BL Name: Jeana Lim Section: A01 Winter 2013

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1 NUT 116BL Name: Jeana Lim Section: A01 Winter 2013 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 low BUN 90 mg/dl high Serum creatinine 14 mg/dl high Creatinine clearance 17.0 ml/min high Serum sodium 142 meq/l WNL Serum potassium 5.7 meq/l high Serum albumin 2.8 g/dl low Hgb /Hct 11.5 g/dl/28% low/low Serum transferrin 155 mg/dl low BP 160/100, standing, right arm high Urine ph 7.31 WNL Serum phosphorus 5.0 mg/dl high PTH 100 pg/ml high Urine volume 450-mL/24 h low 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) (NTP p. 527) Since blood glucose is not tightly controlled, hyperglycemia occurs which can damage the blood vessels of the kidneys. Kidneys will not be able to regulate blood and produce fluid that will eventually become urine. This can attribute to retention of fluid and sodium which leads to edema. Diabetic nephropathy occurs in correlation with CKD because uncontrolled blood glucose can thicken the glomerulus tissue. Since this has occurred with patient, BK, her kidneys are allowing more protein to be excreted through urine. This process decreases the amount of working nephrons which in turn can lead to azotemia and uremia. 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) According to BK s anthropometrics, she gained 5 kg in the last 10 days. From the subjective point-of-view, BK has been consuming more fluids, according to her dietary intake, than she should be consuming when one has CKD. There needs to be a restriction to her fluid intake because it will add more water weight. She reports she is busy with her family so that s why she doesn t have time to plan her meals. The objective information tells me that since she has been diagnosed with T2DM, her kidneys have been declining since her body is retaining more fluid than necessary. Thus, the weight gain is from the excess fluid even though BK reports of anorexia and N/V.

3 4. Which foods in her usual diet are contributing most to: (2 points) a) Phosphorous levels: Whole milk, cheese, beans b) Potassium levels: Banana, beans, orange juice 5. Explain the rationale for the following interventions: (4 points) a) Phosphate binder: Phosphate binders are used to block excess phosphate from interacting with calcium which could calcify bones if there is excess phosphorus which leads to weakened bones or osteodystrophy. b) Calcium supplement: The parathyroid gland doesn t secrete enough vitamin D to aid in absorbing calcium due to CKD. Calcium supplements will help circulate more calcium in the system so the body doesn t develop muscle spasms. c) Iron and EPO: Complications of CKD includes low iron stores and EPO. Pt on hemodialysis will lower iron stores and EPO. Intravenous iron can be administered and monitor serum iron, total iron binding capacity, and serum ferritin as they are the best indicators of iron and EPO stores. d) Vitamin supplement containing only water soluble vitamin: Those who go through HD will experience increased vitamin loss during dialysis. Vitamins that aids in renal disease includes B vitamins, folic acid, and vitamin C. But high doses of vitamin C should be avoided. 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: Higher protein requirements are required for those on HD or PD because protein is a major source of Nitrogen and contributes to nitrogen balance. Protein has to be accounted for when it s loss through dialysis, inflammation, infection, etc. Serum albumin is low with 2.8g/dL which can be affected by fluid status, inflammation, and urinary protein losses. More protein must be accompanied in the diet and 50% of that protein must be of high biological value. b) Phosphorus restriction: Too much dietary phosphorus can be absorbed in the GI Tract if excess phosphorus cannot be excreted through urine. When phosphorus interacts with calcium, calcification of the bones will occur and can lead to osteodystrophy. BK s phosphorus is high with 5.0mg/dL which is an indicator that she has consumed high phosphorus foods. An ideal range includes 800-1,000mg/d. c) Potassium restriction: Excess potassium in one s body can lead to GI bleeding, catabolism, and hyperglycemia. Limiting a potassium to <2,000mg/d will help stabilize potassium levels. Recommending a diet that is low in potassium is ideal. d) Fluid and/or sodium restriction: Fluid and sodium restriction is highly individualized and is based on urine output and dialysis. Other factors include BP, weight gain in HD patients, and edema. Symptoms of fluid overload includes SOB, HTN, edema, and congestive heart failure. BK s fluid intake was 1774 ml, WNL sodium, high BP of 160/100, and urine volume of 450ml/24hrs which is low. Sodium should be restricted to <2,000mg and fluid to 1.5L/day.

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 D I M+E BK has complained of progressive anorexia with N/V, gained 5kg in the past 10 days, edema, inability to urinate, and fatigue. She was diagnosed with T2DM at 12yo but wasn t adhering to treatment recommendations. She is hypertensive as well since she has high BP of 160/100. BK was diagnosed with CKD stage 3 two years ago with acute symptoms x 10 days but is now in CKD stage 4 due to her treatment of nutrition consult and preparing for kidney replacement therapy. Anthropometrics - Female, 42 yo, CBW = 71.82kg (+ 5kg), UBW = 66.82kg, ABW = 65.37kg, Ht = 62 - BMI (UBW)= kg/m 2, BMI (ABW)= kg/m 2, IBW = kg, %IBW = % (UBW), %IBW = % (ABW) Lab Values BUN 90 mg/dl high Serum sodium 142 meq/l WNL Serum potassium 5.7 meq/l high Serum phosphorus 5.0 mg/dl high PTH 100 pg/ml high Diet Rx: Renal diet of kcals, 78.44g protein, 2g sodium, 2g potassium, and 1g phosphorus diet, 1.5L fluid restriction. Vitamin/mineral supplement as well. Requirements: Energy = kcals/d, Protein = g/dl, Fluid = 1.5L fluid restriction Medications: Metformin, Lasix, Vasotec, Phos Lo, Sodium Bicarbonate, EPO, Iron. % of Needs (24 hr intake vs. estimated needs) % of Nutrients Estimated Daily Needs 24 Hr Recall Intake Needs Protein (g) % Kcals % Na+ (mg) % K+ (mg) % P (mg) % Fluid (ml) % Excessive mineral intake (sodium, potassium, and phosphorus) r/t limited adherence to nutrient related recommendations aeb irregular lab values of 142 meq/l sodium, 5.7 meq/l potassium, and 5.0 mg/dl phosphorus. Recommendations - Better food choices (low sodium, potassium, phosphorus & fluid restriction) - Re-educate pt on how important it is to adhere to diet recommendations pertaining to Renal disease - Provide pt Renal Diet SMART Goals Follow Renal diet pattern 4x/wk immediately until the pt reaches full compliance of Renal diet within one month. Monitor - Monitor BP daily & lab values weekly, keep track of daily food intake, re-educate pt as necessary Evaluate - Daily intake and adherence, make appropriate recommendations as necessary

5 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) It is normal for weight to change in between HD sessions. There is dry weight and fluid weight. Dry weight can be gained by dietary means in which weight accumulates after a meal without the excess fluid. It s considered the lowest weight one can gain after dialysis. Since the kidneys do not function normally, HD patients get their dialysis treatment about 3x/wk for 4 hours, thus, their bodies will hold onto more fluid which gives the impression one has gained weight during the in-between treatment days. 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) BK has not been consuming the protein amount of 78.44g/day that I have recommended for her because based on her UUN of 7.4g/24 hr, she has been consuming 71.25g protein which is less than the estimated amount. Even though the consumed amount is slightly less than the estimated protein amount, she still should try to consume at least 78.44g protein. Because she is on dialysis, she is losing protein through dialysis and inflammation thus, she should be consuming more than the minimal amount. 10. The patient tells you she sometimes uses a salt substitute. Is this appropriate and why or why not? (1 point) No, salt substitutes contain potassium chloride which is added potassium. This could increase potassium levels without the patient s knowledge. It s best to stick with the recommended renal diet.

6 Renal Diet Pattern Diet prescription- Include 2 gm sodium, 2 gm potassium, and 1 gm, phosphorus diet with a 1.2 L fluid restriction Food (# choices) Kcal Pro (g) Na (mg) K (mg) Phos (mg) Meat (7) Nondairy Milk Substance (3) Starch (8) Vegetable Low K+ (6) Fruit Low K+ (3) Fat (2) Extra Honey (1) *Fluids Lemonade, sugar-free (1) *Fluids Water (5) TOTAL *Fluid = 48oz x 29.57ml = ml