Case Study: Renal Disease

Transcription

1 Case Study: Renal Disease Laboratory Values: Lab Units Patient Normal Source Interpretation GFR ml/min 46 above 90 Renal Lecture 2 BUN mg/dl NTP A-90 Serum creatinine mg/dl NTP A-90 Creatinine clearance ml/min Serum sodium meq/l NTP A-90 WNL Serum potassium meq/l NTP A-90 WNL Serum albumin g/dl NTP A-90 Urine ph WNL 24-hr urine protein g/l Urine specific gravity mg/ml WNL Urine volume ml/24 hr 2, Hgb g/dl NTP A-90 Hct % NTP 1. In the table of laboratory values above, complete the column labeled Normal by entering the expected normal values for this patient. In the column labeled Source, indicate which source you used (such as NTP page 500 ) for each lab value. (8 pts) 2. In the table of laboratory values above, for the column labeled Interpretation, indicate whether the values are high ( ), low ( ), or within normal limits (wnl). (6 pts) 3. Jenny has Nephrotic syndrome and renal insufficiency. In terms of chronic kidney disease, what stage is she in and how do you know? (2 pts) She is stage 3 because her GFR is 46 ml/min and the GFR range for stage three CKD is ml/min (NTP). Also, her altered laboratory values such as high BUN, high Serum Creatinine, low albumin and low Hct further indicate inadequate renal sufficiency. 4. Why was Jenny placed on a 2-3 g Na diet? (2 pts) Sodium restriction is often prescribed for renal patients with hypertension and with BP values of 135/90, this patient is just barely considered hypertensive because she is at or ablve 140/90. Also, pt c/o edema which may potentially be attributed to osmotic pressure differences related to Na levels. Too much sodium can exacerbate these problems. 5. Name two additional laboratory values you might ask for to determine whether the patient is at risk of developing skeletal abnormalities associated with kidney disease. (2 pts) Calcium and Phosphorous 6. The patient s complaints of anorexia and weight gain seem incompatible with the fact that she has gained weight recently. Explain how these conditions can coexist. (2 pts) 1

2 This patient is losing her appetite, anorexia, while having edema which is the accumulation of excess fluid in cells, tissue, or a cavity, resulting in swelling, leading to weight gain. Edema is a hallmark of Nephrotic syndrome (NTP). There have been two mechanisms proposed to explain this. The underfill model occurs when there is a decrease in plasma albumin leading to a decrease in difference between interstitial and plasma oncotic pressure and thus plasma volume contraction. Edema occurs when the amount of fluid flowing into the interstitium exceeds maximal lymph flow. The second explanation suggests that renal disease creates primary sodium and water retention, leading to plasma volume expansion and increased capillary hydrostatic pressure. Overall, fluid retention has resulted in weight gain. However, she has likely lost lean mass. Uremia may be causing the reported anorexia. 7. A protein restriction was not ordered for this patient; was this appropriate or not? Using your book, what would you recommend with regard to her protein level? Provide justification for your recommendation. (2 pts) Recommendation: g/kg; No restriction, but we need to keep in mind where this patients is going and monitor her labs. Also, it is important to use high biological value protein with a good variety of EAA. High protein diets increase workload of the nephron. However, in most cases it s not that patients need to be on a low protein diet but rather that they are eating a high protein diet and need to reduce. High phosphorous and high acid-forming diets are actually bigger problems that protein. Also, studies find that vegetable and dairy protein sources seem okay whereas meat protein, but again, protein of a high biological value is important (116B Lecture). 8. Write one PES statement. (2 pts) Altered nutrition related laboratory values (N.C.-2.2) r/t loss of albumin in the urine and, overall, renal insufficiency AEB low GFR (46 ml/min), creatinine clearance (40 ml/min), serum albumin (2.2 g/dl), Hgb (9.7 g/dl), Hct (32%) and high BUN (40 mg/dl), serum creatinine (2.5 mg/dl), 24-hour urine protein (12 g/l), and urine volume (2,000 ml/24 hour). PART II: Medical Management of Renal Insufficiency 9. Write a PES statement. (2 pts) 2

3 Altered nutrition related laboratory values (N.C.-2.2) r/t stage 4 kidney dysfunction causing severe decrease in GFR and, overall, renal insufficiency AEB low blood HCO3- (14.8 meq/l), transferrin (155 mg/dl), GFR (20 ml/min), creatinine clearance (17 ml/min), serum albumin (2.8 g/dl), Hgb (11.5 g/dl), Hct (28%), urine volume (500 ml/24 hour) and high serum alkaline phosphatase (180 units/l), PTH (100pg/mL), serum phosphorous (5.0 mg/dl), serum potassium (5.7 meq/l), BP (160/100), BUN (90 mg/dl) and serum creatinine (4.35 mg/dl). 10. Explain the purpose of each of the following interventions, and list the data (laboratory parameters, symptoms, etc.) indicating the need for treatment. (10 pts) Sodium bicarbonate Purpose: metabolic acidosis Evidence of need for treatment: low blood bicarbonate (14.8 meq/l) and urine ph (7.31) Protein restriction Purpose: minimize azotemia and nitrogenous wastes Evidence of need for treatment is high BUN (90 mg/dl) and complaints of itchiness, weakness, unpleasant taste and N/V all indicative of extra nitrogen in the blood Phosphorus restriction Purpose: Decrease blood phosphorous levels because this effects the bones. Reduce the amount of Phosphorous that the kidneys have to filter and preserve bone strength. Evidence: High serum phosphorous (5.0 mg/dl), high PTH (100pg/mL), and alkaline phosphatase (180 units/l) Potassium Restriction Labs show that she is high in potassium so we need to find these sources and reduce them in the diet. Side effects include, heart attack, arrhythmias. Also not filtered well by the kidneys when impaired, we can see that from potassium levels Fluid restriction Kidneys aren t filtering enough fluid due to GFR also this patient exhibits edema, and blood pressures are extremely high. Evidence: high blood pressure (160/100) and her urine pattern 11. When you see Jenny in the nutrition clinic, you note that the diet prescription does not specify a calorie requirement. Using your book, how many kcals would you recommend? Show your calculations. (2 pts) 3

4 Using dry weight provided of 52kg x 35kcal/kg = 1820 kcal 12. The patient tells you she sometimes uses a salt substitute. Is this appropriate and why or why not? (2 pts) She should avoid salt substitutes because salt substitutes contain potassium chloride which can further exacerbate her condition (renal lecture #2). 13. Jenny asks for help determining if her favorite foods are OK to eat. Using your book, next to the food below list whether it is high or low in potassium. (3 pts) Orange high Blackberries low Lentils high Spinach high Milk high White rice low 14. Jenny also wants to know if they contain phosphorous. Using your book, next to the food below list whether it is high or low in phosphorous. (3 pts) Orange low Blackberries low Lentils high Spinach high Milk high White rice low 15. Jenny tells you that she feels thirsty all the time. She would like to have more fluid, but the attending physician is reluctant to allow this. She says that she needs most of her fluid allowance to take her medications. What tips could you suggest to her? (2 pts) Limit high-salt foods so you will have less thirst Take your pills with your mealtime liquids, applesauce or pureed fruits, as allowed Drink from small glasses and cups Drink only when you are thirsty. Reach for very cold beverages. Beverages that are less sweet will quench your thirst. Weight yourself daily. You should not gain weight more than the prescribed number of pounds each day. Use sour candy or sugar-free gum to moisten your mouth. Try special thirst-quencher gums. Add some lemon juice to water or ice. The sour taste will help to quench your thirst. Try swishing your mouth with very cold water or low-alcohol mouthwash when you are thirsty. Do not swallow it! Brush teeth often, good mouth hygiene is essential. Keep lips moist with lip balm or moisturized lipstick. Use ice cubes instead of liquids. One cup of ice is equal to ½ cup of water/juice and will last longer. Freeze grapes and eat throughout the day as one of your fruit servings. Try frozen blueberries and pineapple tidbits fruit cocktail, and other recommended fruits. 4

5 Remember that some foods should also be counted as fluids. These include soups, Popsicles, sherbet, ice cream, yogurt, custard and gelatin. PART III: Hemodialysis 16. How much protein and calories per day would you recommend for Jenny and why? (refer to lecture on March 5 th, NTP and the KDQUI Guidelines) (4 pts) Energy: 50kg + [(56-50kg) x 0.25] = 51.5kg x 35kcal/kg = kcal use her adjusted body weight (NTP page 539 table 18.4) WHY: because her history of weight change. Also, we want to avoid weight loss in this patient. Protein: Considering her protein goals: g/kg x 51.5kg = g protein WHY: we do this because hemodyalisis has increased protein needs that are lost in dialysate. 17. Explain the rationale for the following interventions: (4 pts) a) Phosphate binder binds phosphorous. This intestinal absorption of phosphorous, will decrease harmful levels of phosphate. Dialysate does what it can, but it is not always the best at removing it. b) Calcium supplement: Patient is going to lose a lot of calcium. We want to increase Ca absorption, because the ultimate issue is her bone health. In addition, the kidneys are required for vitamin D activation, and prevent renal-osteodystrophy from renal disease. For the kidney function we are relying on the EPO. c) Iron and EPO in renal disease impairs the bodies ability to make EPO. Patients get anemia as a result of dialysis, just to produce enough RBC s. Overall her kidneys aren t functioning well. We need iron to make RBCs, so the two work together d) Vitamin supplement containing only water soluble vitamins are recommended because water soluble vitamins are what you are losing in hemodialysis. Fat soluble vitamins are stored in the adipose tissues. Dialysis loses water soluble vitamins and not so much the fat soluble, because these are stored in the fat cells and not lost in the urine. An exception to this rule is vitamin D because it is the only one synthesized in the body, but the kidney isn t functioning properly to get adequate levels. 18. As a dialysis patient, give albumin and prealbumin goals and why. (2pts) The goals are: 30 mg/dl for prealbumin 4 g/dl for albumin These are falsely elevated because of edema, and this extra fluid can alter these values. 5

6 Albumin 4.0 is a marker of wellness that is sensitive to fluid. It is falsely elevated due to end stage renal disease and/or poor urinary excretion. Prealbumin is more sensitive to nutritional status. We as clinicians aim for higher numbers because we know that they are falsely elevated. The question is, if they are lower than that, how low are they? We aim for those numbers so that the actual value are falling within range. EXTRA Credit (5 pts) Summarize the Therapeutic Lifestyle Changes (TLC) for patients with CKD and state why they are important. Saturated fat <7% Polyunsaturated fat up to 10% of total kcal monounsaturated fat up to 20% of total kcal total fat 25-35% of total kcal CHO 50-60% of total kcal PRO ~15% of total kcal Cholesterol <200mg/day total kcal balance E intake and E expenditure fiber g/day w/5-10 soluble TLC is important for CKD patients because they have significant comorbid conditions in addition to high blood pressure, including diabetes, CVD, obesity, and hyperlipidemia, for which these dietary modifications as part of a comprehensive intervention lifestyle will impact for the better to reduce stroke and coronary artery disease (NTP). Heart disease is a big issue in renal patients! They are very high risk for CVD and stroke. EXTRA Credit (5 pts) What are the nutrition goals for acute transplant period and the chronic period post transplant patients? List 3 nutrients and provide recommendations for the acute and chronic period ACUTE: Manage the increased metabolic demands of transplant surgery. The acute phase lasts up to 8 weeks following the transplant. CHRONIC: In addition to achieving optimal nutrition status, the goals of the transplant diet in the long term include the management of obesity, blood pressure, insulin resistanec, diabetes, and hyperlipidemia; maintenance of electrolyte balance and maximized bone health. The chronic phase begins in the ninth week following transplant. Nutrient Acute Phase Chronic Phase Protein g/kg; based on standard 1.0 g/kg; limit with chronic graft adjusted body weight dysfunction Calories 30%-35% kcal/kg; may increase Maintain desirable weight with postoperative complications Carbohydrates 50%-60% of total kcal; limit simple CHO is tolerance is apparent 50%-60% of total kcal; emphasis on complex CHO and g dietary fiber (5-10) g per day soluble fiber) 6