Kody Springsteen Chronic Kidney Disease/Hemodialysis Case Study

November 13, 2015

“I have not given, received, or used any unauthorized assistance on this assignment” _________________________________________ _____________

Value Patient’s Value Goals for Dialysis Patients

Reason

Sodium 135 mEq/L 136-144 mEq/L Low due to water intoxication due to fluid retention

drugs Potassium 4.4 mEq/L 4.5-5.5 mEq/L Low due to renal

disease Chloride 111 mEq/L 98-107 mEq/L High due to

anemia or renal insufficiency

CO2 15 mEq/L 22-29 mEq/L Low due to renal failure

Calcium 7.5 mg/dl 8.4-9.5 mg/dl Low due to elevated

phosphorous Phosphorous 10.2 mg/dl 4.5-5.5 mg/dl High due to

ESRD BUN 108 mg/dl 60-80 mg/dl High due to renal

failure Creatinine 14.0 mg/dl 2-25 mg/dl Normal Albumin 3.2 g/dl 4.0 g/dl or greater Low due to

edema, renal failure

Hemoglobin 8.3 g/dl 11-12 g/dl Low due to anemia

Hct 24.3% 33-36% Low due to anemia

Transferrin sat 18% 20-50% Low due to anemia

MCV 70 fl. 78-93 u3/RBC High due to anemia

WBC 8.7 109/L 3200-10,600/uL High due to trauma or tissue

injury Urine protein 320 mg/24 hours <30 mg/24 hours High due to

hypertension Medications: The purpose of Lasix is to treat fluid retention in in people with a kidney disorder.

• Drug: nutrient reactions: May need to increase K and Mg. May need to decrease calorie and sodium intake.

The purpose of Lisinopril is to treat high blood pressure because it is an ACE inhibitor, which helps lower the intra-glomerular pressure and reduce proteinuria.

• Drug: nutrient reactions: Need to have adequate fluid intake. May need to decrease sodium and calorie intake. Lisinopril has high MG content, may need to increase K intake.

The purpose of Metroprolol is to treat hypertension as a beta-blocker. • Drug: nutrient reactions: May need to decrease calorie and sodium intake.

The purpose of Renvela is to serve as a phosphate binder for use in ESRD. • Drug: nutrient reactions: Decrease phosphorous in diet.

The purpose of Zemplar is to treat secondary hyperparathyroidism. • Drug: nutrient reactions: Should get adequate Ca (not excessive) and have a low

phosphorous diet. EPO serves as an antianemic.

• Drug: nutrient reactions: May need Fe, Vit B12, or Folate supplement. ESRD diet compliance mandatory.

The purpose of Ferrlecit is to serve as an antianemic during dialysis. • Drug: nutrient reactions: Need 200 mg of Vit C, 30 mg of Fe, take carbonate

antacids, Ca, P, Zn, or Cu supplements separately by 2 hours. Increase Vit A intake to decrease Fe mobilization from stores.

Assessment: Kcal: 25 kcal/kg x 69 kg = 1725 kcal Protein: 1.2 g pro/kg x 69 kg = 83 g pro Pro: 83 g = 332 kcal = 19% of Kcal Phosphorous: 12 mg PO4 x 69 kg = 828 mg PO4 K: 2400 mg/39 = 60 mEq Na: 2300 mg Fluid: 1000 ml/day Fat: > 30 en% = 518 Kcal/9 = 58 g SW’s current intake is not meeting the recommendations. He seems to have a diet high in diary products, which is good for protein, but high in phosphorous. He also eats high potassium fruits, which should be limited since he has CKD and is in dialysis. He also has some nutrient: drug interactions with his current intake and the medications he is on.

Exchange #

Servings C P F Na

(mg) K

(mg) P

(mg) Milk Low Fat .5 6 4 - 60 190 115 Fruit

Low K (Watermelon ½ cup) Med K (1 Apple)

High K (1 banana)

1 1 1

15 15 15

- - -

- - -

15 15 15

100 200 350

15 15 15

Vegetable Low K (4 spears asparagus)

Med K (Carrots ½ cup) High K (1/2 cup spinach)

1 1 1

5 5 5

2 2 2

- - -

15 15 15

100 200 350

20 20 20

Bread (reg-white) 7 97 19 - 560 245 245 Meat (med fat) 8 - 56 40 200 600 520 Fat (reg) 8 - - 40 440 80 40 Totals 163 81 80 1290

(2300) 2225

(2400) 910

(828) Kcal: C: 163 x 4 = 652 P: 81 x 4 = 324 F: 80 x 9 = 720 = 652 + 324 + 720 = 1,696 1725-1696 = 29 Kcal/3.8 = 8 g sugar Percent HBV 60 g (meat and milk)/ 81 g total = 74.1% (70-75%) Fat 720/1725 = 41.7% (30%) PES Statements: Impaired nutrient utilization (NC-2.1) R/T CKD and dialysis AEB hyperparathyroidism and elevated phosphorous levels. Intervention:

1. Eat adequate amount of calories with a reduction in foods that contain phosphorous and potassium.

2. Limit fluid to about 4 cups a day (1000 ml). 3. Incorporate phosphate binders into meal and snack times. 4. Educate patient on what kind of diet they should be eating (low phosphorous, low

potassium, high protein, high calcium). 5. Educate patient about role of kidney in the body.

Monitoring/Evaluation: Monitor lab values to make sure they are meeting the goals for patients on dialysis. Take blood every month. Follow up visit one-month post-operation. Monitor fluid a few times a week. Monitor medication intake. Monitor physical signs of edema.

Food and nutrition-related knowledge deficit (NB-1.1) R/T high phosphorous diet AEB 24 hour recall (dairy products) and elevated phosphorous lab values. Intervention:

1. Avoid foods containing phosphorous and potassium. 2. Try to eat more protein and calcium. 3. Educate on type of foods to eat (low phosphorous meats and grains and know how

much potassium is in the fruits and veggies). 4. Increase physical activity levels post-operation.

Monitoring/Evaluation: Monitor food intake using diet recalls. Monitor labs and GFR to make sure SW is making appropriate changes to diet and lifestyle. Monitor fluid intake a few times a week. Follow-up visit to answer any questions about renal diet. Excessive phosphorous intake (NI-5.10.26) R/T high phosphorous diet AEB 24 hour recall (dairy products) and elevated phosphorous lab values. Intervention:

1. Avoid foods containing phosphorous. 2. Educate on foods that contain high and low amounts of phosphorous. 3. Educate patient about role of kidney in the body. 4. Educate patient on function of phosphorous in the body.

Monitoring/Evaluation: Monitor food intake using diet recalls. Monitor lab values to make sure SW is making appropriate changes to his diet. Follow-up visit to answer any questions about phosphorous, the renal diet, or the kidneys. Secondary hyperparathyroidism is the excessive secretion of parathyroid hormone in response to low blood calcium levels. This patient is at risk because he had CKD and is on dialysis. Most dialysis patients exhibit secondary hyperparathyroidism. The consequences are vascular and valvular calcification, such as non-atherosclerotic coronary artery calcification, aortic calcification, cardiac valve calcification, and non-cardiac vascular calcification. Prescription drugs, dialysis, a kidney transplant, or surgery manages it medically. It is managed nutritionally by increasing vitamin D and calcium intake, as well as avoiding phosphate in the diet. Wu Q, Lai XL, Zhu ZY, et al. Evidence for Chronic Kidney Disease-Mineral and Bone Disorder Associated With Metabolic Pathway Changes. J Med. 2015; 94(32):e1273. doi: 10.1097/MD.0000000000001273