NUT 116BL Name: ___________________________________ Section: _________ Winter 2013

Case Study #3: Renal Disease 50 points

1. Please be concise and use only the space provided. 2. Please cite sources as necessary. 3. You may use your textbook, the pocket resource, and drugs.com 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 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

Ivana Wu A02

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 Laboratory: Lab Value Interpretation GFR 15 mL/min BUN 90 mg/dL Serum creatinine 14 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 /Hct 11.5 g/dL/28% Serum transferrin 155 mg/dL BP 160/100, standing, right arm Urine pH 7.31 Serum phosphorus 5.0 mg/dL PTH 100 pg/mL Urine volume 450-mL/24 h

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) 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)

T2DM is due to body's lack of insulin to transport sugar from blood into the cells. Uncontrolled diabetes will result in too much sugar remaining in bloodstream and over time the high levels of blood sugar can damage the vessels in the filtering units of the kidneys. The vessels will eventually become clogged and narrow. The lack of flowing blood will cause damaged kidneys and increase albumin excretion in urine. Diabetes can also damage the nerves in your body that sends messages to your brain that your bladder is full. The result of a full bladder can cause kidney damage.

BK is probably isn't eating well and is having N/V so patient may think (subjective) that she is losing weight. However, since patient does have +3 edema (objective), lots of water and solutes retained in the body are contributing an actual weight gain (objective).

4. Which foods in her usual diet are contributing most to: (2 points) a) Phosphorous levels:

b) Potassium levels: 5. Explain the rationale for the following interventions: (4 points)

a) Phosphate binder

b) Calcium supplement

c) Iron and EPO

d) Vitamin supplement containing only water soluble vitamin

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

b) Phosphorus restriction

c) Potassium restriction

d) Fluid and/or sodium restriction

Quesadillas, tortillas, milk, eggs, chicken, cheese, ice cream

Orange juice, quesadilla, banana, apple juice, milk, tortilla, ice cream

Chronic Kidney disease causes trouble in removing phosphorus in body resulting in high serum levels of phosphorus. (NTP 541) Not using phosphate binder might result in high levels of phosphurs. Help control levels of phosphorus by preventing gastrointestinal absorption of dietary phosphorus.

Kidney disease can cause bone metabolism imbalance. This causes a decreased absorption of calcium in the gut and elevated phosphorus level results in low serum calcium in CKD patients. Requirement for calcium is higher. Dietary rich foods are also high in phosphorus, so it should be so calcium should be obtained from supplementation. Calcium supplement may also be used as a phosphate binder to control high serum levels of phosphorus. (NTP p.541)

Most of body's EPO is produced in the kidneys. Kidney disease may cause damage in cells that make EPO, resulting in anemia. Iron and EPO supplementation will help supply body with red blood cells, preventing anemia. Not using iron and EPO might result in decrease of red blood cells and anemia. (NTP 544)

There is an increase loss of vitamins during dialysis. Water soluble vitamin is recommended for CKD patients since it is easily excreted and needs to be replaced daily. Also, patients with kidney disease usually lack water soluble vitamins because many fruits, vegetables whole grains, and diary produces are not allowed in CKD diets. Fat soluble vitamins are not advised since they do not excrete as well and can be toxic if serum levels are too high. (NTP 544)

Recent evidence shows that low-protein diets are effective in slowing the progression of renal disease. It can also delay progression of albuminuria and glomerular filtration rate decline. Protein restriction will limit the build up of nitrogenous wastes produced from protein metabolism. Kidney damage will not be able to remove these wastes. Labs: serum transferrin (if low), albumin (if low) , BUN (if high), creatinine (if high), N balance (if negative). Symptoms: muscle wasting.

To prevent hyperphosphatemia, manage bone disease and soft tissue calcification. CKD patients' glomerulus filtration rate decreases, so the kidney's ability to excrete phosphorus decreases as well, resulting in hyperphosphatemia. Labs: serum calcium (if low), serum phosphrous (if high), GFR (if low) , PTH (if low). Symptoms: altered nerve transmission and muscle contraction. (NTP 541, 132)

CKD patients have an inadequate excretion of potassium. Restriction will prevent cardiac events, such as normal heartbeat. Labs: serum potassium (if high) Symptoms: muscle weakness, paralysis, paresthesias, cardiac dysrhythmias (NTP 131)

Patients with acute renal failure have decreased urinary output, so CKD kidneys can't accommodate rapid fluid ingestion. Restriction will control blood pressure and maintain fluid balance. Having high fluids will change blood volume and hypotension since electrolytes are abnormal in CKD patients. Electrolyte imbalance can cause hypernatremia. Labs: blood pressure (if high), urine output (if low), rapid weight change, serum sodium (if high), plasma osmolality (if high) Symptoms: edema, difficulty breathing, rales, lethargy, agitation to seizures and coma, elevated body temp, flushed skin, dry mucous membrane (NTP 127, 130)

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 well-balanced Renal Diet for her to follow using the attached renal diet pattern document. (8 points)

A: BK is a 42 yr F diagnosed with chronic kidney disease, hypertension, T2DM, and hyperlipidemia. Patient's kidney function has been declining for the last 5 years with anemia, decreased GFR, and increased creatinine, phosphate and urea. Family history of T2DM. Patient complaints of progressive anorexia with N/V, 5kg weight gain in the past 10 days, edema, fatigue, worsening SOB with 2 pillow orthopnea, pruritus, and inability to urinate. Patient is prepared for kidney replacement therapy.

Ht: 5'2"= 1.57m Wt: 158lbs= 71.8kg UBW: 66.8kg BMI: 27.1 (overweight) IBW: 110lbs= 50kg %IBW: 143.6% (obese) LABS: GFR: 15mL/min (low) BUN: 90mg/dL (high) serum creatinine: 14mg/dL(high) creatinine clearance: 17mL/min (low) serum albumin: 2.8g/dL (low) Hgb/Hct: 11.5g/dL/28% (low) serum transferrin:155mg/dL (low) PTH:100pg/mL(high) Urine volume: 450-mL/24h(high) +3 pitting edema MEDICATIONS: Metformin, Lasix, Vasotec, Phos Lo, Sodium Bicarbonate, EPO, Iron

24 HOUR RECALL: Energy: 3527 kcals (high) PRO: 134g (high) K+: 4443mg (high) Na+: 5205mg (high) Phos: 2635mg (high) REQUIREMENTS: Energy: 2287.25 kcals PRO: 78.42-85g Fluids: 1000mL/d K+: 2-2.5g/d Na+: 2-3g/d P: 800-1000mg/d

D: Undesirable food choices related to nutrition knowledge deficit as evidenced by 24 hr recall, recent diagnosis of acute renal failure, low GFR, Hct, serum transferrin, BMI, weight gain, and %IBW.

Per patient's usual intake, patient is currently exceeding calorie, protein,potassium, sodium and phosphorus nutrient needs. Patient is unaware of her weight gain because of her symptoms of progressive anorexia and N/V. However, patient has +3 pitting edema, indicating fluid retention, resulting in 5kg weight gain in the past 10 days. Rhonchi with rales and orthopnea also indicates fluid build-up. Therefore, patient should reduce sodium and phosphorus intake to decrease fluid retention. Increased protein is necessary for patient's kidney replacement therapy due to increased losses during dialysis. The renal diet can be an option for hemodialysis. Patient's diagnosis and family history indicates T2DM; patient would benefit from better diet management to delay progression. Patient does not seem very compliant as she complains of lack of time to manage diet.

I: Goals: - Patient should maintain a daily intake of about 2287.25 kcals for the next month to spare protein - Patient should consume between 78.42 to 85g of protein in everyday diet for the next month to preserve muscle mass and serum proteins and replenish losses from hemodialysis - Patient should adhere to daily renal diet of a 2gm sodium, 2gm potassium, and 1 gm phosphorus diet for the next month - Patient should adhere to 1.5 fluid restriction in everyday diet for the next month to minimize fluid retention Recommendations: - Diet rx of 2287.25kcals/day, 78.42-85g PRO/day, 2gm sodium, 2 gm potassium, and 1gm phosphorus diet - Education on renal diet pattern and food choices - Take renal vitamin and mineral supplementation each day to insure adequate nutrition

M/E: Monitor and evaluate: 1. Keep food records 2. Keep weight log 3. Monitor GFR, BUN, creatinine clearance, serum albumin, Hgb, Hct, serum transferrin, serum phosphate, Na and K values Follow up: next check up in 3 days to see progress, then will follow-up once every week for the next month

Ivana Wu R.D. 2/27/13 11:11am

Follow up visit 1 month later

Feb 25 Feb 27 BUN, mg/dL 97.0 99.0 Body wt, kg 68.2 69.4 UUN, g/24 hr 7.1 7.4

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)

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)

10. The patient tells you she sometimes uses a salt substitute. Is this appropriate and why or why

not? (1 point)

It is normal for patients to experience weight fluctuation in-between sessions. Goal for HD patients is to have 5% of body weight gain but should not exceed this. High fluid gains can lead to change in blood volume and hypotension. To minimize weight change, patients are recommended a 2g sodium diet with a fluid restriction of 1L daily. This is due to patients having low urine output and absence of urine formation. If urine output is more than 1 L a day, sodium and fluid intake can be slightly increased.

Patient's nitrogen balance is positive indicating adequate amounts of protein to support recommendations are met. Positive nitrogen balance reflects anabolism. (NTP 61)

This is not appropriate because most salt substitutes are potassium based. So using substitutes could result in hyperkalemia which is something to be aware of in CKD patients. (NTP 131)

Renal Diet Pattern Diet prescription- Include 2 gm sodium, 2 gm potassium, and 1 gm, phosphorus diet with a 1.2 L fluid restriction

Food (# choices)

Kcal

Pro (g)

Na (mg)

K (mg)

Phos (mg)

Meat

Milk

Bread

Vegetable

Fruit

Fat

Extra

Fluids

TOTAL

8

0

9