Educational Intervention in Chronic Kidney Disease

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1 Educational Intervention in Chronic Kidney Disease Presented by: Megan Lasko NFS 562 Case Study Presentation University of Rhode Island MS in Dietetics February 18, 2017

2 Presentation Format and Abbreviations Format I. Introduction II. NCP: Presentation of Clinical Case III. Discussion IV. Conclusion Abbreviations NCP = Nutrition Care Process CKD = Chronic Kidney Disease = Potassium GFR = Glomerular Filtration Rate

3 I. Introduction: Nutritional Relevance of CKD? Protein Potassium* Sodium Phosphorus Fluid *This presentation has a particular focus on dietary The Nephron Image Source: By OpenStax College - Anatomy & Physiology, Connexions Web site. Jun 19, 2013., CC BY 3.0,

4 II. NCP Step 1: Assessment Patient: HJ Age: 73 Sex: M Wt: 72.7 kg (160 lb) Ht: 1.68 m (5 6 ) Admit Dx: Near Syncopal Episode Medical History: CKD Stage III T2DM Aortic Stenosis and Atrial Fibrillation s/p aortic valve replacement (November 2016) Other Active Problems: HTN, HLD, vitamin D deficiency Surgical History: Aortic Valve Replacement and Ligation of Left Atrial Appendage in November 2016

II. NCP Step 1: Assessment Present Medical Status:

Nephrology Nutrition Services: Patient has been

5 II. NCP Step 1: Assessment Present Medical Status: Near syncopal episode (secondary to diuretic medication changes) Complex Hx + Abnormal Labs=Hospital Admission Consults: Cardiology Nephrology Nutrition Services: Patient has been having difficulty w/ his diet given cardiac, kidney, and diabetes diagnoses.

6 II. NCP Step 1: Assessment LABS LAB VALUE INTERPRETATION 6.1 mmol/l - (normal ) Diet? BUN 22 mg/dl WNL Dietary protein? Creatinine 2.03 mg/dl (normal: ) Estimated GFR 32.4 ml/min/1.73m 2 (desirable: >60) Acute reduction in renal blood flow? Stage III CKD 1

7 II. NCP Step 1: Assessment MEDICATIONS MEDICATION DRUG TYPE PATIENT INDICATION Apixiban (Eliquis) Anti-coagulant A. fib ASA Platelet aggregation inhibitor Hyperlipidemia Atorvastatin (Lipitor) Anti-hyperlipidemic Hyperlipidemia Bisoprolol (Zebeta) Anti-hypertensive Hypertension Cholecalciferol (vitamin D) Supplement/Calcium regulator CKD/hx of D deficiency Fenofibrate (Triglide) Anti-hyperlipidemic Hyperlipidemia Furosemide (Lasix) Anti-hypertensive loop diuretic Hypertension Amiodarone Anti-arrhythmic A. Fib Potassium Chloride (K-dur) Electrolyte/mineral supplement K-depleting diuretics Toresemide (Demadex) Anti-hypertensive loop diuretic Hypertension

8 II. NCP Step 1: Assessment Social History Retired x 7 years Lives at home with wife Cardiac rehabilitation participant Diet History Hx diet education w/ RD (DM & Cardiac) Compliant Breakfast Lunch Dinner Oatmeal w/ Splenda and Cinnamon Cranberry or Orange Juice Turkey Medallions Fruit (banana, cantaloupe) Yogurt Chicken Breast Baked Potato Fresh veggies Large side salad w/ tomatoes Snacks: fruit (banana, cantaloupe), yogurt, unsalted potato chips Fluids: 6 bottles water/day with sugar-free Crystal Lite Estimated Daily Protein Intake: 73 g/day (estimated via SuperTracker 2 )

9 II. NCP Step 1: Assessment Diet Order: Pre-Renal (Non- Dialysis) Inpatient Diet History* K: ~2 g K: <2.4 g P: ~1500 mg P: mg Protein: 70 g (represents 1 g/kg HJ s body weight) Na: ~3 g AND EAL Recs 3 Protein: g/kg body weight Na: <2.4 g *Patient reports good appetite, consuming 100% of meals. C/o small portions.

10 II. NCP Step 1: Assessment Energy Needs Protein Needs AND EAL for CKD: kcal/kg body weight to prevent signs of malnutrition AND EAL for CKD: g/kg: patients w/o DM *Doesn t apply g/kg: patients w/ DM nephropathy *Doesn t apply K/DOQI: g/kg: CKD w/ DM APPLIES! kcal x 72.7 kg= kcal HJ S Energy Needs 0.8 g protein x 72.7 kg=58 g HJ s Protein Needs

11 II. NCP Step 2: Diagnosis Food and nutrition-related knowledge deficit (NB-1.1) related to lack of previous renal diet education in patient with CKD stage III as evidenced by patient reports no knowledge of the foods and nutrients that are pertinent to CKD diagnosis.

12 II. NCP Step 3: Intervention Tackling the Task of Renal Diet Education: What was my method? Review of Labs (P: not available, BUN: WNL, K: ELEVATED!) Diet History=Major Key! Breakfast Lunch Dinner Oatmeal w/ Splenda and Cinnamon Cranberry or Orange Juice Turkey Medallions Fruit (banana, cantaloupe) Yogurt Chicken Breast Baked Potato Fresh veggies Large side salad w/ tomatoes Snacks: fruit (banana, cantaloupe), yogurt, unsalted potato chips Fluids: 6 bottles water/day with sugar-free Crystal Lite Estimated Daily Protein Intake: 73 g/day (estimated via SuperTracker 2 ) Final Verdict: Focus on Potassium!

13 II. NCP Step 3: Intervention The dietetic intern will provide nutrition education on: 1) sources of -rich foods, particularly those present in the patient s current diet regimen, 2) recommendations for replacing, reducing, or removing them (E-1.5), and 3) individualized daily intake recommendations with specific information on how to determine intake levels (E-2.3). To more comprehensively meet the patient s educational needs, the dietetic intern will refer the patient to the facility s outpatient RD for additional MNT (RC-1.2).

14 II. NCP Step 3: Intervention Short-Term Goals: The patient will be able to verbally state 3 -rich foods present in his current diet (bananas, cantaloupe, potatoes, tomatoes) and 3 lower foods to replace them (berries, pineapple, cooked carrots) by the 3-day nutrition review. To further meet diet education needs, the patient will schedule an appointment for MNT with the outpatient RD by the time of discharge. Long-term goals: The patient will effectively reduce dietary intake to <2.4 g/day (as prescribed by the AND EAL for patients with hyperkalemia 2 ) to facilitate normal serum levels by 3 months post-discharge.

15 II. NCP Step 4: Monitoring & Evaluation Short-term, inpatient M&E: Monitor: Further education needs, Labs (but consider strict pre-renal diet) Evaluation: Verbal-teach back of education Long-term, outpatient M&E: Monitor: Continued monitoring for education needs and lab values Evaluate: Hyperkalemia prevention, hospital readmissions A note on prognosis in CKD: Turin et al: 4 GFR= life expectancy year life expectancy w/ HJ s GFR 32.4 ml/min/1.73 m 2

16 III. Discussion Part 1: Pathophysiology Potassium Homeostasis: Cellular Level a A Human Cell Extracellular Space This is a carefullymaintained intra- to extracellular gradient! K + a Information adapted from Kovesdy et al 5

17 III. Discussion Part 1: Pathophysiology a Adrenal Gland ALDOSTERONE Potassium in: Dietary Sufficient tubular flow Potassium in = Potassium out Functional principal cells a Information adapted from Kovesdy et al 5 URINARY EXCRETION of

18 III. Discussion Part 2: Intervention Rationale Rationale for Hyperkalemia Prevention Hughes-Austin et al (n=9,651) Luo et al (n=55,266)* Nakhoul et al (n=36,359)* Serum >5.0 meq/l Serum >6.0 meq/l Serum >5.0 mmol/l All-case mortality* CVD death* non-cvd death* *All risks > in diuretic users Mortality Major adverse cardiovascular events Hospitalizations Mortality *Subjects w/ CKD

19 III. Discussion Part 2: Intervention Rationale Rationale for Recommending Dietary Restriction AND EAL for CKD: 3 <2.4 g /day for comprehensive approach to hyperkalemia and related adverse cardiovascular outcomes Kovesdy 2015: 5 Goal of chronic hyperkalemia management: To prevent the development of hyperkalemia by identifying and correcting the proximal defect(s) in potassium homeostasis. This typically starts by eliminating correctable causes, such as high potassium intake in diet or in supplements, hyperkalemia-inducing medications, or metabolic acidosis.

20 III. Discussion Part 2: Intervention Rationale Rationale for Educational Strategy and Content Cuppari et al 9 Recommendations Nutritional counseling to lower dietary when serum approaches 5.0 mmol/l Recs to inform about: HJ Case/Intervention HJ s serum was 6.1 mmol/l on admission Informed HJ about: Foods that contain a significant amount of Foods specific to HJ s diet that contained significant amount of (bananas, tomatoes, potatoes, etc.) How much of that they should consume Provided handout with specific K food serving sizes and respective amounts. Personalized daily K goal for HJ <2.4-3 g

21 III. Discussion Part 3: Medications Several Medications w/ -Alterting Effects! Torsemide (Demadex) + Furosemide (Lasix): K-depleting Loop diuretics (anti-hypertensives) K-Dur: Potassium chloride supplement (compensate for Loop-induced loss) Bisoprolol (Zebeta): Beta-blocker (anti-hypertensive): inhibits renin production alters homeostasis

22 IV. Conclusions Effectiveness of Nutritional Care: Verbal nutrition review: successful! Patient scheduled appointment w/ outpatient RD What would I do again? Individualized approach to renal diet education What would I do differently? More collaboration with interdisciplinary care team Future research: RCTs w/ high vs. low diet effect on serum Next slide: Questions for my colleagues!

23 IV. Conclusions Your Opinion is Wanted! Was my diagnosis appropriate? Consideration of Excessive potassium intake (NI ) Thoughts on the Pre-Renal (non-dialysis) hospital diet? (see slide 9) Too restrictive for the inpatient setting? What does the research say? Critical analysis of my approach to renal diet education: What do you do differently? Any tips for improvement?

24 References 1. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;32(2 Suppl 1): S SuperTracker. United States Department of Agriculture website. Accessed February 13, Chronic kidney disease (CKD) guideline (2010): CKD: Executive summary of recommendations. Academy of Nutrition and Dietetics Evidence Analysis Library website. Accessed February 13, Turin TC, Tonelli M, Manns BJ, Ravani P, Ahmed SB, Hemmelgarn BR. Chronic kidney disease and life expectancy. Nephrol Dial Transplant. 2012;27(8): Kovesdy CP. Management of hyperkalemia: An update for the internist. Am J Med. 2015;128(12): Hughes-Austin JM, Rifkin DE, Beben T, et al. The relation of serum potassium concentration with cardiovascular events and mortality in community-living individuals. Clin J Am Soc Nephrol. 2017;12(2): Luo J, Brunelli SM, Jensen DE, Yang A. Association between serum potassium and outcomes in patients with reduced kidney function. Clin J Am Soc Nephrol. 2016;11(1): Nakhoul GN, Huang H, Arrigain, et al. Serum potassium, end-stage renal disease, and mortality in chronic kidney disease. Am J Nephrol. 2015;41(6): Cuppari L, Nerbass FB, Avesani CM, Kamimura MA. A practical approach to dietary interventions for nondialysis-dependent CKD patients: the experience of a reference nephrology enter in Brazil. BMC Nephrol. 2016;17(1):85.

NFS 561 Case Study Presentation: Heart Failure. Presented by: Megan Lasko University of Rhode Island MS in Dietetics December 10, 2016

NFS 561 Case Study Presentation: Heart Failure Presented by: Megan Lasko University of Rhode Island MS in Dietetics December 10, 2016 I. Subjective/Objective Data Patient: CC Age: 59 Presenting symptoms: