Case Study: Renal Disease

Transcription

1 Name: Melissa Hayes Case Study: Renal Disease 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 fl oz. 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 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

2 Laboratory: Lab Value Interpretation GFR 15 ml/min Low (renal failure) BUN 90 mg/dl High Serum creatinine 14 mg/dl High Creatinine clearance 17.0 ml/min Low Serum sodium 142 meq/l WNL (diluted w/edema) 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 Low 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) Diabetic nephropathy along with uncontrolled blood sugar levels associated with Type-2 DM increases the risk of developing CKD and kidney damage. There is a thickening in the glomerulus and changes in the basement membrane of the renal tissue, which leads to increased albumin excretion, and increased destruction of glomeruli. This destruction leads to a concentrated workload of individual nephrons. The clearance limits of the individual nephrons are reached and levels of solutes in body fluids increase. This leads to azotemia and uremia, common symptoms of CKD. (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) Due to her CKD, BK has increased fluid rendition and edema. This fluid retention has caused weight gain in spite of anorexia and non-fluid weight loss. Subjectively, the weight gain would indicate that the nutritional status of the patient is adequate, and despite complaints of anorexia the patient must be eating. An objective assessment would show the edema and signs of fluid retention, indicating that fluid retention is most likely the cause of the weight gain. 4. Which foods in her usual diet are contributing most to: (2 points) a) Phosphorous levels: Dairy (cheese, whole milk, ice cream), beans, corn tortilla (quesadillas and plain), any chocolate or nuts in cookies, fruit punch (Tampico) b) Potassium levels:

3 Orange juice, banana, milk, beans, tomatoes in salsa, any nuts or chocolate in cookies 5. Explain the rationale for the following interventions: (4 points) a) Phosphate binder Prevents the absorption of dietary phosphorus and helps to decrease serum phosphorus levels. This is important because increased phosphorus levels are associated with increased mortality of patients on dialysis. If serum phosphorus, calcium is draw from the bone and this can lead to osteodystrophy. b) Calcium supplement Calcium requirements are increased in CKD patients due to the vitamin D metabolism changes that interfere with calcium uptake, decreased gut absorption, and higher serum phosphorus levels that bind to free calcium. Since Vitamin D activation is limited, the calcium uptake by the bone decreases, increasing calcium need. Supplements may also be necessary because by following the renal diet and limiting phosphorus, calcium intake normally decreases since foods that are high in calcium are commonly high in phosphorous as well. Intake (dietary, binders and supplements) however, should not exceed 2,000 mg/day on a renal diet. The Phos-lo that BK will be taking is calcium based, so an extra supplement may not be requires in this case. c) Iron and EPO In CKD, the kidneys cannot maintain their proper function and produce the endogenous hormone EPO. The decrease in EPO leads to decreased red blood cell production and low hemoglobin. Iron supplementation can help reduce severity of iron-deficient anemia, and many CKD patients need artificial EPO (rhuepo) to increase RBC production. Without these treatments, RBC number will remain low, oxygenation to tissues will decrease, and the patient will remain in an anemic state. d) Vitamin supplement containing only water soluble vitamin There is fluid loss during dialysis treatments, and with this fluid loss the water soluble vitamins are also excreted. This loss during dialysis along with the dietary restrictions of fruits and vegetables, whole grains and dairy products leads to water soluble vitamin supplementation needs. Without this supplementation, malnutrition and deficiencies may occur. 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 A low protein diet during the early stages of CKD before dialysis treatment is important to reduce the nitrogen and nitrogen-containing compounds in the body since nitrogen cannot be adequately excreted in the urine as urea. It is also important to minimize uremia. Increased nitrogen levels appear as increased BUN and creatinine levels along with edema, and these indicate a need for treatment. b) Phosphorus restriction Phosphorus restriction can help reduce soft tissue calcification (ie arteries) due to the phosphorus interaction with calcium. High phosphorus levels in the blood, low GFR (20-30 NTP.541) and low urine output would indicate the need for treatment of a restricted mg/day phosphorus intake. c) Potassium restriction High serum potassium levels can lead to fatal heart arrhythmias. High serum potassium levels and low urine output indicate a need for treatment of a less than 2,000mg/day intake. d) Fluid and/or sodium restriction Fluid and sodium restriction minimizes weight gain between dialysis treatments and helps reduce edema status. Severe edema, low/no urine output, shortness of breath and hypertension indicate a need for fluid and sodium restriction. 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 wellbalanced Renal Diet for her to follow using the attached renal diet pattern document. (8 points) A: 42 YO F, CC progressive anorexia with N/V, 5 kg weight gain in 10 days, edema, fatigue, worsening SOB

4 with 2 pillow orthopnea, pruritus and anuria. Presents with 3+ pitting edema, muscle weakness, rhonchi with rales. Preparing for kidney replacement therapy. Pt Hx: Type-2 DM dx at age 12, inconsistent adherence to treatment. Renal function has been declining over past 5 years with anemia, decreased GFR, and increased creatinine, phosphate and urea. Nutrition Hx: Reports usual intake high calorie, high protein, high sodium and phosphorus diet. Dx of CKD 3 years ago, acute symptoms x 10 days, HTN, hyperlipidemia. Meds: Lasix, Metformin (inconsistent), Vasotec (not-refilled) Labs: Indicate kidney failure and signs of respiratory acidosis GFR 15 ml/min (low, renal failure) BUN 90 mg/dl (high) Serum creatinine 14 mg/dl (high) Creatinine clearance 17.0 ml/min Serum sodium 142 meq/l (WNL- diluted value d/t edema) Serum potassium 5.7 meq/l (high) Serum albumin 2.8 g/dl (low) Ht: cm Wt: 71.8kg Hgb/Hct 11.5 g/dl/ 28% (low- anemia) Serum transferrin 155 mg/dl (low- iron def.) BP 160/100 (high- HTN) Urine ph 7.31 (low, indicate acidosis) Serum phosphorus 5.0 mg/dl (high) PTH 100 pg/ml (high) Urine volume 450 ml/24 hr (low) Adjusted BW: 65.35kg %ABW: 109.9% IBW: 50kg %IBW: 143.6% Current BMI: 28.9 (Overweight) Adjusted BMI: 26.3 (Overweight) Kcal needs: 2,287.3 kcal/day EPN: >78.4 g/day (50% from HBA source) Fluid: 1,450ml (about 1.5 L) to limit ID weight gain D: PES: Unintended weight gain (NC-3.4) R/T fluid retention caused by CKD AEB 5kg wt gain in 10 days, 3+ pitting edema, fatigue and SOB. I: Goal: Meet nutritional requirements, prevent malnutrition, minimize uremia and associated CKD complications, and maintain BP and fluid status. Recommendations: Begin hemodialysis 3x/week Renal diet of <2g sodium, 2g potassium, 1g phosphorus, 2g calcium (including binder), 1.5L/day fluid restriction, >78g protein/day (50% from highly bioavailable source), 2,300 kcal/day (decreased from usual intake) Renal vitamin/mineral supplement, Phoso Lo binder with meals Renal diet education for patient, diet exchanges Recommend to MD patient stop Lasix use while on dialysis (or any diuretic) (PR p.119), Lasix and Vasotec may be additive on lowering BP and cause hypotension (ACE inhibitors and diuretics), Vasotec or Lasix and Metformin may be additive on lowering blood glucose and cause hypoglycemia. M/E: Weight check before and after each dialysis treatment for dry weight, and adherence to fluid restricted diet. Recommend food diary to monitor kcal, protein, Na, K, Phos intake (can use renal food choices) Weekly BP checks to monitor fluid and HTN status Monthly labs to monitor adherence to renal diet and phosphate binder use (serum phosphorus, sodium, potassium), check for malnutrition/ deficiencies (D, iron, B12), Hb/Hct to monitor anemia Blood Glucose Checks monthly, hemoglobin A1C every 3 months to monitor diabetes control Follow up visit 1 month later Feb 25 Feb 27 BUN, mg/dl Body wt, kg UUN, g/24 hr

5 8. 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) In-between HD sessions there will be weight gain due to fluid retention and decreased urine output. Following the renal diet recommendations, especially fluid and sodium restriction can minimize this weight gain. Immediately following the HD treatment, BK will be at her lower dry weight, after the fluid has been filtered out. 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) No, she is under the daily recommendation. She is consuming about 7-9 grams less than 78 grams of protein I have recommended for her to maintain adequate protein status during her hemodialysis treatments. Her current intake, reflected by her UUN levels are about 69.4g and 71.3g of protein respectively. Nitrogen Balance (0)=(protein intake (g)/6.25)-(uun+4) 2/25: 0= Protein Intake/6.25- (7.1+4) 2/27: 0= Protein Intake/6.25- (7.4+4) 11.1=Intake/ = Intake/6.25 Intake= 69.4 g protein Intake= 71.3 g protein 10. The patient tells you she sometimes uses a salt substitute. Is this appropriate and why or why not? (1 point) No, salt substitutes are not appropriate as they are high in potassium (made with KCl), and potassium is restricted on the renal diet. If her potassium levels are WNL (without dilution from edema), then these salt substitutes may be considered in small amounts.

6 Calculations/References: Ht (cm)= 62 x 2.54 cm/in=157.5 cm Current Wt (kg)= 158#/2.2#/kg= 71.8kg Current BMI= 71.8/ =28.94 IBW= (2)= 110# or 50 kg (P.R. p.32) %IBW= 64.5kg/61.36kg= 143.6% IBW (P.R. p.34) UBW (kg)= 66.8 kg (edema free) SBW (medium frame)= 61kg Adjusted BW= edema free BW+ ((standard BW-edema-free BW)x.25) *for overweight =66.8 kg + ((61kg-66.8kg)x.25) =65.35 kg (NTP p.539) %ABW= 71.8kg/65.35 x100%= 109.9% Adjusted BMI= 65.35/ =26.34 Kcal needs= 35kcal/kg (ABW)= 35kcal/kg (65.35kg)= 2,287.3 kcal/day (NTP p.536) EPN= 1.2kg/day (due to increased needs during HD) =1.2g/kg (65.35kg)= >78.4g protein/day (50% high biological value) Fluid= output ml (limit weight gain between dialysis treatments) (NTP p. 536) 450 ml+ 1000ml= About 1.5 L