NUT 116BL Name: CHRISTINE WOO Winter 2014 Section: 1 Final Case Study: Renal Disease Due 3/19/14 60 points Part I: Initial Presentation Present Illness: Jenny is a 19 yo F student referred to the renal clinic at the UC Davis Med Center for evaluation of renal function. She had c/o fatigue, weakness, anorexia, edema, and sudden weight gain. The clinic obtained the following information: Past Medical History: T&A at age 7; streptococcal infection of throat at age 11, followed by glomerulonephritis; fractured arm at age 14 Family History: Both parents A & W. Brother age 16 A & W. Social History: Single, lives with parents. Review of Systems: Patient c/o nocturia 1-2 times/night; fatigue; anorexia; mild pruritis. Examination: White female; 5 6 ; 134 lbs (pre-illness wt 124 lbs); medium frame. BP 135/90, right arm, sitting. P70, regular. R 15. T 37 C. Fundi normal. Lungs clear. Heart without murmur or gallop. Extremities show 2+ pedal edema. Albuminuria 3+. Rest of exam WNL. Impression: Nephrotic syndrome with renal insufficiency in 19 yo normal weight female with medical history of post-streptococcal glomerulonephritis. Plan: Nutrition referral for instruction on 2-3 g Na diet. Rx: Furosemide (Lasix) 60 mg qd, RTC in 1 wk for BP check and blood draw for serum Na, K; renal ultrasound. Laboratory: Lab Units Patient Normal Source Interpretation GFR ml/min 46 90-120 p.526 NTP Low BUN mg/dl 40 10-20 p.532 NTP High Serum creatinine mg/dl 2.5 0.5-1.1 p.532 NTP High Creatinine clearance ml/min 40 75-115 Low Serum sodium meq/l 142 136-145 p.534 NTP WNL Serum potassium meq/l 4.0 3.5-5 p.533 NTP WNL Serum albumin g/dl 2.2 3.5-5 p.532 NTP Low Urine ph 6.2 6.0-8.0 WNL 24-hr urine protein g/l 12 2-8 High Urine specific gravity mg/ml 1.003 1.003-1.030 WNL Urine volume ml/24 hr 2,000 600-1600 WNL Hgb g/dl 9.7 12-16 p.533 NTP Low Hct % 32 37-47 p.533 NTP Low
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) Jenny is at stage 3 of CKD, which is a moderate decrease in GFR, according to her GFR lab values. Right now, she would need to be monitored and treat complications. 4. Why was Jenny placed on a 2-3 g Na diet? (2 pts) Jenny was placed on a 2-3 g Na diet to restrict Na and lower her blood pressure because she is currently pre-hypertensive. 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) Her serum-ca and phosphorous which can measure for osteodystrophy. 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) The signs of anorexia and weight gain can be explained due to edema, a common side effect of NS patients (p.552 NTP) 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) Yes, this is appropriate because protein is needed to preserve muscle mass. Her albumin levels are also low, another reason why restricting protein would not be appropriate at this time. 0.8-1 g protein/kg/day x 60.9 kg = 48.7 60.9 g per day (p.534 NTP) 8. Write one PES statement. (2 pts) Altered nutrition-related lab values r/t loss of albumin a.e.b 24-hour urine value. PART II: Medical Management of Renal Insufficiency Jenny continued on this program of conservative management for the next 6 years. During this time, she graduated from college, began her career as an elementary school teacher in a rural
community, and got married. She was followed by her personal physician and was not seen in the renal clinic for several years. At the age of 25, she was again referred to the renal clinic. She c/o more frequent headaches, nausea and vomiting, severe itching, an unpleasant taste in her mouth, muscle cramps and twitching, weight loss, weakness, and drowsiness with difficulty concentrating. The examination and interview provided the following information: GFR 20 ml/min BUN 90 mg/dl Serum creatinine 4.35 mg/dl Creatinine clearance 17.0 ml/min Serum sodium 142 meq/l Serum potassium 5.7 meq/l Serum albumin 2.8 g/dl Hgb 11.5 g/dl Hct 28% Serum transferrin 155 mg/dl BP 160/100, standing, right arm Proteinuria Negative Urine ph 7.31 Serum phosphorus 5.0 mg/dl PTH 100 pg/ml Serum alkaline phosphatase 180 units/l - Blood HCO 3 14.8 meq/l Urine volume 500 ml/24 h Dry weight 52 kg (estimated by urologist) Impression: Chronic renal failure in a 25 yo underweight female with history of renal insufficiency and nephrotic syndrome. Plan: Nutrition referral for diet counseling: protein 40 g; Na 1.5 g; K 2.5 g; Phos 1 g; fluids output + 500 ml Rx: furosemide (Lasix) 60 mg TID; Adomet 250 mg TID; sodium bicarbonate 1 g TID 9. Write a PES statement. (2 pts) Altered nutrition-related lab values r/t renal insufficiency and nephrotic syndrome a.e.b increased serum potassium, increased serum sodium, increase serum phosphorous values. 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) a) Sodium bicarbonate Purpose: treat metabolic acidosis Data: low ph value, low blood HCO3
b) Protein restriction Purpose: treat azotemia Data: high BUN, itchiness, potassium levels, increased creatinine level, nausea/vomit c) Phosphorus restriction Purpose: treat hyperparathyroid Data: increased PTH, increased phosphorous, alkaline phosphatase d) Potassium restriction Purpose: potassium function impaired from kidney; not filtering out, building up Data: from increased potassium lab value e) Fluid restriction Purpose: decrease edema Data: high blood pressure 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) 52 kg x 35 kcal/kg/day = 1820 kcals per day (p. 536 NTP) 12. The patient tells you she sometimes uses a salt substitute. Is this appropriate and why or why not? (2 pts) No, because many salt substitutes contain potassium chloride, and she needs to restrict potassium due to build-up and kidney filtering impairment. 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 (p.540 NTP) 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 (p. 543 NTP, lecture Renal Disease part II, slide 25)
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) Some tips to decrease thirst would be applying lip balm, eating sour candy, limit high Na foods, add lemon juice to her water, and drink from small glasses. (p.541 NTP) PART III: Hemodialysis Jenny is no longer able to keep up her work at the school. Her GFR is now 16 ml/min. Her physician recommends a transplant, but a kidney is not immediately available. As a consequence, hemodialysis is recommended. An arteriovenous fistula is surgically created in Jenny s left forearm. A month later, she is admitted to the hospital. Her serum potassium level has risen further and BUN is 110 mg/dl. Her BP has also risen. She is started on hemodialysis 5 hr/day, 3 days a week. Her diet prescription now reads: Na 2 g; K 3 g; phosphorus 1.2 g; fluid 1,500 ml/d. She is given prescriptions for a phosphate binder, a calcium supplement, and a vitamin supplement that does not contain vitamin A. She will receive IV EPO and Fe. Her pre-dialysis weight is 56kg and her post-dialysis weight is 50 kg. 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) Adjusted weight = 50kg + (56-50) x 0.25 = 51.5 kg (p. 539 NTP) (1.2-1.5) g protein/kg/day x 51.5 kg = 61.8 77.3 g protein/day (p.536 NTP) Recommended to ensure adequate amount of amino acids. 35 kcal/kg/day x 51.5 kg = 1803 kcal/day (p.536 NTP) Recommended because prevent catabolism and achieve optimal nutritional status. 17. Explain the rationale for the following interventions: (4 pts) a) Phosphate binder Phosphate binders help to prevent GI adsorption of dietary phosphorous. In HD patients, higher protein needs is idea. (p. 541 NTP) b) Calcium supplement Lost of calcium with phosphorous so supplementation is needed to substitute lost. Impaired calcium adsorption occurs in renal patients, so Ca supplements will also help to prevent bone disease. c) Iron and EPO RBC burst during hemodialysis, so Fe would help produce more RBC. EPO production is also impaired in renal patients and decreased during HD.
d) Vitamin supplement containing only water soluble vitamins Water-soluble vitamins that are critical to health are being lost through HD, so supplements would substitute for that. 18. As a dialysis patient, give albumin and prealbumin goals and why. (2pts) Albumin: greater than or equal to 4 for renal disease patients, which is the same as normal patients. Pre-albumin: greater than or equal to 30 for renal disease patients because these patients show falsely elevated pre-albumin levels from metabolic processes in body. (Lecture Renal Part II slide 15) EXTRA Credit (5 pts) Summarize the Therapeutic Lifestyle Changes (TLC) for patients with CKD and state why they are important. Saturated fat: 7% of total kcal PUFA: up to 10% of total kcal MUFA: up to 20% total kcal Total fat: 25-35% total kcal CHO: 50-60% total kcal Protein: 15% total kcal Cholesterol: >200mg/day Total kcal: prevent weight and maintain body weight Fiber: 20-30g/day with 5-10 g soluble fiber (p.539 NTP) This is important because renal patients have increased risks of CAD 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. Goals of acute post-transplant patients are to manage increased demands after surgery. Chronic and long term goals are to maintain nutritional status to prevent obesity, manage blood pressure, insulin resistance, diabetes and hyper-lipidemia. (p.547 NTP) Acute transplant period: Protein: 1.3-5g/kg Cals: 30-35% kcals Fats: 25-35% kcals Chronic transplant period: Protein: 1.0 g/kg Cals: maintain desirable weight Fats: 25-35% kcals