FND 431 Clinical Experience Case Study! Introduction!

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1 FND 431 Clinical Experience Case Study Jennifer Millard Introduction Ms. B is a Type II diabetic with ESRD who has been receiving dialysis since April of Previously, she has shown excellent compliance with her renal diet and a stable dry weight of 55 kg. Last month, Ms. B was hospitalized with C. difficile. After resolution of the infection she was sent home, but symptoms have returned. Weight loss, diarrhea, reduced appetite and altered lab values for albumin and phosphorus precipitated referral to the registered dietitian. Assessment Data Ms. B is a 67 year old female, 64 inches tall. Her usual body weight is 55 kg, but her current dry weight is 53.1 kg. Average weight gain between dialysis is 0.7 kg. Recently, Ms. B reported she has had a reduction in appetite. In addition, a 1.9 kg dry weight loss over the last month was recorded. This is a 3.6% weight loss in one month. Ms. B is divorced, retired, lives alone, and needs assistance with daily activities. Ms. B reports fatigue and inability to prepare nutritious meals for herself that comply with her renal diet. She also mentioned during her counseling session that she has been eating cheese and drinking juice. Both of these items are high in phosphorus, and this addition to her diet may be a contributor to increased phosphorus levels (7.7 mg/dl, Table 1). Ms B was questioned regarding her use of phosphorus binders at mealtime, but she seemed to have little recollection of taking them. This, in addition to reports of fatigue and inability to prepare meals indicated she may have need of in-home help for her meals and a reminder for medications such as her phosphorus binder. Ms. B has stage III end stage renal disease (ESRD) requiring dialysis. She is currently receiving hemodialysis three times a week. She has several medical diagnoses that affect her nutritional status: Type II diabetes (T2DM), congestive heart failure (CHF), hypertension (HN), dyslipidemia, and anemia secondary to chronic kidney disease (CKD). Ms. B was recently hospitalized for C. difficile. She is still experiencing diarrhea, and recurrence of C. difficile is suspected. A physical exam showed she is anuric, has edema (1+) in her lower extremities, has a stage three pressure ulcer (1.3x0.5cm), and also a wound on her back (20.5cmx0.3cm). According to the DaVita lab guide, Ms. B s blood glucose (BG) is within normal limits (221 g/dl, see Table 1 at end of document). The lab was taken in a non-fasted state, so the value for BG that appears high is fine for her condition. In addition, her HgA1C is high for an average, healthy adult, but is lower than 7%, which is within DaVita s cutoff standard for a Type II diabetic on dialysis. At this point, the anemia, as evidenced by Hgb 10.0 g/dl (Table 1), is being treated with epogen and venofer/iron sucrose which is administered at the time

2 of dialysis. Ferritin and iron saturation are within normal limits. Nutrition intervention will not improve serum hemoglobin levels. Her wounds and diarrhea are of particular concern. Combined with lack of appetite, increased energy and protein needs due to ESRD/hemodialysis, and reduced intake, these conditions may be responsible for Ms. B s weight loss and low serum albumin (2.8 g/dl, Table 1). Ms. B is currently using one can of Nepro (425 kcal/can, 19.1 g protein/can) daily as an oral supplement, as well as one ounce of Liquacel (90 kcal/oz, 16 g protein). Medications include: epogen, renal vitamin, ergocalciferol, venofer/iron sucrose, lasix, renvela, celexa, atorvastatin, fentanyl, synthroid, ativan, metoprolol, nitroglycerin and vancomycin. Medications of Nutritional Concern (1): Epogen: Recombinant human erythropoietin; used to treat anemia in ESRD. Nausea, vomiting and diarrhea may be side effects. Renal Vitamin: Replaces B vitamins lost in dialysis. Ergocalciferol: Vitamin D; increases calcium absorption. Venofer: Ferrous salts for iron deficiency treatment via IV. Taste loss, nausea, vomiting, and diarrhea are possible side effects. Lasix: Loop diuretic; increases excretion of potassium, however loss of potassium is not a concern for Ms B because she is anuric. Potassium supplementation is unnecessary. Cramps, nausea, vomiting and diarrhea may be side effects. Renvela: phosphate binder, decreases absorption of phosphate. Celexa: antidepressant; may cause dry mouth, increase weight or appetite. Atorvastatin: HMG-CoA reductase inhibitor; reduces total colesterol, reduces LDL and triglycerides. Fentanyl: narcotic for pain relief; side effects include dry mouth, dyspepsia, nausea, vomiting, abdominal pain, constipation, or diarrhea. Synthroid: thyroid hormone; possible side effects are appetite changes and weight loss. Ativan: antianxiety; may cause changes in weight or appetite. Metoprolol: antihypertensive; may cause diarrhea.

3 Nitroglycerin: for angina, must take with water on an empty stomach. Side effects may include dry mouth, nausea, vomiting or abdominal pain. Calculations: BMI = 53.1 kg/1.62 m ^2 = 20.3 EER = 53.1 kg(35 kcal/kg) = 1,859 kcal/day Protein requirement = 53.1 kg(1.2 g/kg) = 64 g protein per day Nutritional Diagnosis Inadequate protein and energy intake related to fatigue and inability to prepare nutritious meals as evidenced by 1.9 kg unintended weight loss in one month and serum albumin 2.8 mg/dl. Intervention Plan Debilitation, recent illness and advanced age all contribute to Ms B s inability to consume adequate energy and protein in compliance with her renal diet. Weight loss and severely reduced albumin levels indicate nutrition intervention is needed. A diet with adequate protein and energy, as well as appropriate levels of sodium, phosphorus, and potassium is needed to optimize Ms. B s outcome on dialysis. She cannot prepare these meals herself; so outside help is needed, and that is reflected in the intervention explained below. The most important goal right now is to increase protein and energy intake to avoid further weight loss. High phosphorus levels will be addressed in more depth at her follow up consultation. -Patient will continue Nepro and Liquicel to supplement energy and protein intake. -Patient will receive nutritious meals that comply with the renal diet and are appropriate for a Type II diabetic (consistent carbohydrate) delivered to her home from Angel Heart Meals. This will encourage adherence to the renal diet and provide sufficient calories and protein to replenish serum albumin and prevent further weight loss. It was calculated that 515 kcals and 35 g of protein are being provided by Nepro and Liquicel kcals and 29 g of protein will be provided by the Angel Heart meals. -In home help will be recommended to supervise meals and medications. Availability of family members to perform this function will be assessed. -Patient will take prescribed phosphorus binders with meals.

4 Monitor/Evaluate Patient will continue to be monitored according to labs and other parameters listed below: -Weight will be taken at each dialysis session (pre and post dialysis). -Continue to monitor labs, particularly albumin for protein status, with frequency according to Table 1. -Intake estimates will be obtained via report of in-home help. Chart Note Assessment: Pt is 67 year old female, 64 inches tall. UBW 55 kg. Current dry wt 53.1 kg. Avg wt gain btwn dialysis 0.7 kg. Pt reports reduction in appetite. 2 kg wt loss (dry wt) over the last month. Pt is divorced, retired, lives alone, and needs assistance with daily activities. Pt reports fatigue and inability to prepare nutritious meals for herself that comply with her renal diet. Pt reports lack of adherence to renal diet by eating cheese and drinking juice. BMI 20.3, EER 1,859 kcal/day, estimated protein needs 64 g/day. Medical Hx: Stage III ESRD requiring dialysis, type II diabetes, CHF, hypertension, dyslipidemia, and anemia secondary to CKD. Recently hospitalized for C. difficile. Diarrhea, recurrence of C. difficile suspected. Physical exam shows edema (1+) in lower extremities, anuric, stage 3 pressure ulcer (1.3x0.5cm), wound on her back (20.5cmx0.3cm). One can of Nepro daily as an oral supplement, as well as one ounce of Liquacel. Medications include: epogen, renal vitamin, ergocalciferol, venofer/iron sucrose, lasix, renvela, celexa, atorvastatin, fentanyl, synthroid, ativan, metoprolol, nitroglycerin and vancomycin. Labs: Hgb 10.0 g/dl, albumin 2.8 g/dl, phosphorus 7.7 mg/dl, other values WNL Diagnosis: Inadequate protein and energy intake related to fatigue and inability to prepare nutritious meals as evidenced by 1.9 kg unintended weight loss in one month and albumin 2.8 mg/dl. Intervention: Pt will continue to receive 1 oz Liquicell and 1 can Nepro daily to provide 515 kcal and 35 g protein. Patient will receive Angel Heart Meals consistent with renal diet delivered to her home. Meals will provide 1344 kcal and 29 g protein to meet estimated needs. High biological value proteins will be requested. Pt received counseling regarding the importance of taking phosphorus binders with meals to lower serum phosphorus levels, as well as adherence to renal diet. High phosphorus levels will continue to be monitored and addressed in more depth at her next appointment.

5 Monitoring/Evaluation: Labs pertaining to nutrition and anemia (Table 1) will continue to be monitored on at least a monthly basis, particularly albumin and phosphorus. Pre and post weight will be taken each time pt is dialyzed. In home help will provide intake estimate of delivered meals. References 1. Pronsky ZM, Crowe SRJP. Food Medication Interactions, 17th Ed. Birchrunville, PA, DaVita Dietitian Team. Interpreting Lab Values. DaVita Inc. 2011:1-5.

6 Most Recent Lab Results 14 March: Reference values for DaVita were used to evaluate Ms. B s lab values and are indicated in the chart below (2). Table 1 Test February 14 Davita Lab Reference Desirable for Dialysis Frequency BUN (mg/dl) Monthly Albumin (g/ dl) >4.0 Monthly npcr (g/kg) 0.75 > Monthly CO2 (bicarb MEq/L) Potassium (neq/l) Glucose (not fasting) Monthly Monthly Monthly Hgb A1c 6.3% % <7% Quarterly Cholesterol (mg/dl) Triglycerides (mg/dl) Phosphorus (mg/dl) 101 < Monthly <200 Monthly Monthly Hgb (g/dl) >12 w/ epogen Every two weeks Ferritin (ng/ ml) Iron Saturation Quarterly 24% 20-55% 20-50% Monthly WBC (mm^3) Monthly MCV (FL) Monthly