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HillaryLawson NUT116BL F121PM February27,2013 1.

Lab Value NormalRange

CaseStudy#3Renal Interpretation CaseBasedInterpretation Reference withCKDranges(NTPp.532 533) 1529mL/min Pocket Kidneydamage:severe Reference reductionofGFR pg.109 (recommendationforkidney replacementdialysis)

GFR

15mL/min

Greaterthan90 ExtremelyLow mL/min

BUN

90mg/dL

1020mg/dL

Greaterthannormal 6080mg/dLHypercatabolismPocket andexceedingCKD orexcessiveproteinintake, Reference range inadequatedialysis(p.111) pg.71 Wasteproductthatcomes fromtheproteinweconsume. Normallyremovedbythe kidneys,ahighBUNshows alteredkidneyfunction. TooHigh,butwith 215mg/dL Pocket CKDRange Closetohighend=excess Referencep. protein,inadequatedialysis, 74 muscledamage)p.112 Creatinineisawasteproduct inthebloodfrommuscles,itis normallyremovedbythe kidneys.Whenkidney functionisslowtheclearance islow. Pocket Reference p.80

Serum Creatinine

14mg/dL

.51.1mg/dL

Creatinine Clearance

17.0mL/min 88188ml/min ExtremelyLow forwomen

Serum Sodium Serum Potassium

142mEq/L

136146 mEq/L 3.55.0mEq/L

WNL

5.7mEq/L

ExcessiveKinthe diet,renalfailure, renalHTN

3.56.0mEq/LCKD, Pocket inadequatedialysis,excessive Reference oralintake(highorlowlevels p.79,113 canweakenmusclesand changeyourheartbeat)

Serum Albumin

2.8g/dL

3.55.0g/dL

TooLow *maybebedueto dilution

*idealisgreaterthan4.0g/dLPocket (p.111) Reference *Fluidoverload(nephritic pg.71 syndrome)

Hgb/Hct

11.5g/dL/ 28%

1216g/dl and 3747%

Botharetoolowand1012g/dL/3336% Pocket indicateanemia Renalfailure/renalartery Referencep. stenosis,uremia. 77,112 (anemiaorinadequateESA) Low Lowironstoreslinkedto Anemia,nephrosis anemia. Pocket Reference p.81

Serum 155mg/dL Transferrin BP

250380mg/L

160/100 Lowerthan High Indicatesarterialnarrowing NTPp.289 standing,right120/80mmHg HTNisgreaterthan orplaquebuildup,high arm 140/90mmHg volumefluid 7.31 4.6to8 WNL ApHbelow4.5wouldbevery acidicandcauserenal damage. 3.55.5mg/dL(withinrange) NTP532 CKD,inadequatePbinder 533 (Highlevelscanleadtoweak bonesandcalcificationsinthe bloodwhenboundtoserum calcium)

UrinepH

Serum 5.0mg/dL Phosphorus

3.04.5mg/dL

Toohigh

PTH

100pg/mL

1065pg/mL

TooHigh indicatesapoorbalanceof Pocket calciumandphosphorousin Referencep. Renalhypercalcemiathebodyandcouldcause 79 bonedisease. IndicatespoorkidneyfunctionNTP andCKD

UrineVolume450mL/24hr 800 Lowurineoutput 2000ml/24hr (18.75ml/hr) (basedon2L normalintake)

References:http://www.kidney.org/kidneydisease/understandinglabvalues.cfm http://lifeoptions.org/kidneyinfo/labvalues.php http://www.nlm.nih.gov/medlineplus/ency/article/003425.htm 2.TypeIIDiabetesMellitusisoneofthemostcommoncausesofchronickidneydisease duetoitsaffectontheglomerulusandrenalsoluteload.Ittypicallybecomesariskwith

increasinglyuncontrolledglucoselevels.ApatientwithtypeIIDMhasathickeningofthe glomerulusofthekidney,whichisresponsibleforfilteringthebloodandconsolidatingthe wasteproductsintourinetobeexcretedfromthebody.Asthethickeningofthe glomerulusworsens,moreproteinthannormalislostthroughurine.Afteranincreasing numberofglomeruliaredestroyed,theamountofalbuminexcretedintheurineincreases, whichdecreasestheserumconcentrationofalbumin.Theamountofnephronsdeclines andadiminishednumberofnephronsarelefttohandlethesamesoluteload,whichcauses alimitonhowmuchsoluteisfilteredatatime.Asaresult,thebodyfluidconcentration increasesandleavesthepatientsusceptibletoazotemiaanduremia,aswellasanobvious decreaseinGFR,whichisahallmarkofCKD(NTP.527). 3.AlthoughBKcomplainsofanorexiaandweightloss,shehasgainedweightduetoher highfluidconsumptionandinabilitytofilterandurinateouttheadditionalfluid.Patients withchronickidneydiseasehavereducedorcompletelossofkidneyfunctionandhavean inabilitytofiltertheirblood.Thisinabilitycausesabackupoffluidinthesystemanda highervolumeoffluidretainedinthebody.PatientswithCKDhavetwoweights.Their wetweightistheweightinwhichtheyarecarryingadditionalfluidthatisnoturinated outorfilteredthroughdialysis;thedryweightistheweightinwhichthepatienthasno excessfluidintheirsystemorjustafterdialysis.Excessivefluidinapatientcancause abnormallabvalues,edema,hypertension,andcardiacstress. 4.Whichfoodsinherusualdietarecontributingmostto: a)Phosphorouslevels:Eggs,CornTortillas,IceCream,WholeMilk,Cheese (Quesadillas) b)Potassiumlevels:Tampico(citrusjuice),OrangeJuice,Banana,WholeMilk,Ice Cream Sources: http://www.davita.com/kidneydisease/dietandnutrition/diet basics/phosphorusandchronickidneydisease/e/5306 http://www.davita.com/kidneydisease/dietand nutrition/diet%20basics/potassiumandchronickidneydisease/e/5308 5.Explaintherationaleforthefollowinginterventions: a) PhosphateBinder:Aphosphatebinderisusedtopreventthegastrointestinal absorptionofphosphorousbyactinglikeaspongeandbindinguptheavailable phosphorousinthestomach.UnboundserumphosphorouscancalcifywithCalcium. Typically,highCalciumfoodsarehighinphosphorousaswell;whenthesefoodsare consumed,theexcessphosphorousmustbecontrolledsomehow. b)CalciumSupplement:ACalciumsupplementistypicallygiventoaCKDpatientbecause thereisadeficiencyintheactiveformofvitaminDduetoparathyroidhormone(PTH)loop inhibition.PTHisinvolvedwiththeregulationofcalciuminthebodybystimulating calciumreabsorption,phosphorousexcretion,andtheactivationof VitaminD,whichthen stimulatestheabsorptionofintestinalCalcium.Whendamagedkidneysareunableto convertVitaminDtotheactiveform,thePTHloopisdisabled,andbone/mineraldisorders canensue.Highcalciumfoodsaretypicallyhighinphosphorousaswell,whichcanresult incalcificationsinserum.Thus,Calciumsupplementsinconjunctionwithcalciuminthe

dietareusedtomeetrequirementsofCKDpatients.Calciumbasedphosphatebindersare sometimesusedtoincreasecalciumlevelsinpatientswhileloweringphosphateto maintainbone/mineraldensity(NTP524,541). c)IronandEPO:IrondeficiencyiscommonamongCKDpatientsbecausethekidneysare unabletomakeadequateerythropoietin(duringdialysis)forRBCproduction. Erythropoietinismadebytherenaltubularcells;incompromisedkidneys,theRBC productiondeclinesinthebonemarrowandresultsinlowhemoglobin.Recombinant HumanErythropoietinisusedtosupplementCKDpatientsandincreaseRBCproduction. Typically,theeffectivenessoferythropoietindependsonironstatusbecauseRBC productionrequiresagreatdealofiron,whichiswhyCKDpatientsareoftengiven supplements.Untreatedanemiacanresultincardiacorventricularhypertrophy,angina, CHF,malnutritionorimpairedimmunologicalresponses(NTP544545). d)VitaminSupplementcontainingonlyWSV:Duetoincreasedlossesofwatersoluble vitaminsduringdialysis,anorexia,orpoordietaryintake,WSVsupplementsarenecessary. Therenaldietisalsoverylowinfreshfruitsandvegetables,wholegrains,anddairy;these groupsoffoodthatarehighinwatersolublevitamins.RenalWSVsupplementstypically containBvitamins,folicacid,andVitaminC;fatsolublevitaminsandmineralsneednotbe includedinthesesupplements(NTP549). 6.Explainthepurposeofeachofthefollowinginterventionsandlistthedata indicatingtheneedfortreatment:(NTPp.53233) a)ProteinRestriction:Alowproteindietisrecommendedforthoseintheearlystagesof CKD,andahighproteindietisrecommendedforthoseondialysis.CKDpatientsona proteinrestrictionshouldlimittheirproteinintakebecausetheirkidneysareunableto filterthewasteproductsofproteinmetabolism.Byreducingproteinintake,itreducesthe workloadofthekidneysaswellastheriskofazotemiaanduremia,andmaystiflethe progressionofthedisease.However,itisimportantthatthepatientsonlimitedprotein consumeatleast50%highbioavailableproteinforproteinsparing.Lowalbumin(below 3.5mg/dL)andhighproteinwastevalues(Creatinine,CC,BUN)indicatekidneyissues,as wellasadecreasingGFRrateshowingadecreasingabilitytofilter. b)PhosphorousRestriction:Phosphorousinthebodyisusedformaintainingandbuilding strongbonesandteeth,oraidingintheconversionoffoodtoenergy.Kidneydiseasecan preventthebodyfromexcretingphosphorous,causingsecondaryissuesaffectingthe bonesandtheheartbindingwithcalciumintheserum,whichcausescalcificationsinthe bloodandpossibleosteoporosis.Phosphorousrestrictionisusedtocontroltheamountof serumphosphorous.Itisalsoimportantwhenonhemodialysistolimitphosphorous, becausewhenthereisexcessphosphorusintheblood,patientshavecomplainedofitching. Aphosphorouslevelgreaterthan4.5mg/dLindicatesahighserumlevelandinabilityto clear,ahighPTHlevelcanalsobeassociatedwithhighphosphorousandCalcium9greater than65pg/mL). c)PotassiumRestriction:Thekidneysareresponsibleforpotassiumregulation.Inthecase ofchronickidneydisease,potassiumlevelscannotbecontrolled,andthebuildupof potassiumcanresultinhyperkalemiaandundesirablecardiacevents.Potassium

restrictionisimportanttomaintainelectrolytebalancesandpreventcardiacevents.A potassiumlevelgreaterthan5.0mEq/Lcanindicateaneedfortreatment. d)Fluidand/orSodiumRestriction:Fluidandsodiumrestrictionsareusedtocontrolblood pressureandmaintainfluidelectrolytebalances.Thekidneysareresponsibleforfiltering toxinsfromthebloodandduetoreducedkidneyfunctiontheurineoutputisdecreased.A lowerurineoutputmeansahigherfluidloadonthevasculatureofthebodyandtheheart topump.Inordertoreducetheworkloadonthebodyandreducefluidretention,fluidand sodiumrestrictionsareimportant;theycanreducetheriskofedema,hypertension(a commoncauseofCKD),shortnessofbreath,cardiacstress,andfatigue.Asodiumlevel greaterthan146mEq/Lwithedemaindicatesaneedfortreatment.Also,alowurinary outputoflessthan500mLper24hoursindicatesaneedfortreatment. 7.Assessment: Subjective:Patientis42yofemalewithtype2DM,HTN,hyperlipidemia,andCKDthathas progressedfromstage3twoyearsagotonowwherethepatientc/oofaninabilityto urinate,itching(pruritus),andaweightgainof5kgin10days.Thepatientc/oN/V, secondaryanorexia,edema,andworsenedSOB.Patienthas2childrenbothmacrosomicat birthandfindsithardtoadheretoDMorCKDmanagementduetoherbusylifestyle. Objective: LabValues: Anthropometrics: GFR:15ml/min(indicatingnear EdemaFreeW:71.81kg ESRD) SW(Med)=61kg BUN:90mg/dL=High Adj.BW=EFW+(SWEFWx0.25) Work:65.36kg=66.8+((6166.8)x0.25) SerumCreatinine:14mg/dL=high CC:17.0mL/min=low IBW:50kg Albumin=2.8g/dL=Low Ht:1.575m Hgb/Hct=indicateanemia@11.5 %IBW:130.72%(ABW) g/dLand28% BMI(AdjBW):26.5(overweight) RecommendedweightforHDpatients:Transferrin:155mg/dL=Low BP:160/100indicatesStageIIHTN (PRpg.110) ABMIof23.6forwomenforincreasedPhos:5.0mg/dL=High PTH100pg/mL=High survivalrate Urineoutput:450mL/24hr=low 58.54kgor~129lbs Na:WNL K:5.7mEq/L=High DietHistory: Sub3500kcal 34%TotalFat 15%SatFat(11%Mono 5%Poly) 18%Protein Ca:2082mg K:4431mg Phos:2802mgNa:6450mg

Calculations: RecommendedKcalsfor Weightmaintenance: 35kcals/kgBW/dperCKD patients<65yo 2287.6or~2300kcal Protein: Recommended1.2g/kgBW 65.36x1.2=78.43(~80g)PRO Fluid:GainsbetweenHD: 3.3kgWGbrownHDappt. TxFluidPlan: 1.5Lrestriction

RecommendationsforDiet: Sub2300kcal CHO:sub56%(~322g) PRO:79g(~80g)orgreaterthan13.9% Greaterthan50%HBV Fat:lessthan30%totalfat Lessthan77g Lessthan10%SatFat(or26g) 2gmNa.2gmK.1gmPh

Drugs:

Purpose:

NutrientInteractions:

SideEffects:

Metformin

Oralhypoglycemic

AvoidAlcohol

LacticAcidosis,GI distress,chestpain,loss ofappetite(PRp160) Jaundice,anorexia, paresthesias,diarrhea, N/V,dizziness,rash, urticariaetc.9pdr.net) Fatigue,Headache, Dizziness(pdr.net)

Lasix

Treatmentforedema, loopdiuretic

Avoidalcohol, barbituates,and narcotics UsecautionwithK+ containingsalt substitutesor supplements

Vasotec

ACEinhibitorusedto decreaseBPand decreaseHTN

Diagnosis: PES:Unintendedweightgain(NC3.4)R/TprogressionofchronickidneydiseaseAEB5kg weightgainin10dayscounterindicatedbysecondaryanorexia,inabilitytourinate(GFR 15mL/min,UrineVolume450mL/24hr),alteredlabvalues(Albumin2.8g/dL,CC17.0 mL/min,Creatinine14mg/dL,PTH100ph/mL),pittingedema3+withBP160/100, worsenedSOB,N/V(Phosphorous5.0mg/dL[barelynormal],5.7mEq/L),ronchiwith rales,andfatigue. *Ichoseunintendedweightgainasthemainproblemduetothefactthatthe5kg weightispossiblyduetoBKsinabilitytoadheretorecommendationsconcerning hercurrentcondition.ShehasbeenaCKDpatientfor2yearsandaT2DMformostof herlife.Theaddedweightgainmorethanlikelyiscausingtheexacerbated symptomsofedema,HTN,dilution,SOB,fatigue,etc. Stateof:BKisinthecontemplationstageofthetranstheoreticalmodelofbehavior change.BKwasdiagnosedwithtypeIIDMattheageof12withaFMHofthediseaseand wasdiagnosedwithCKDstage3twoyearsago,yetshehasnotmadetherecommended changestoherdietorlifestyleandisnotadherenttohermedicationregiment.Thepatient isawareofhermedicalconditionsbutneglectstofollowatreatmentplanormakesmall changes. Intervention: Meetwiththepatient3timesaweekbeforeHDappointmentsandslowtheimminent progressionoftheESRDtomortality. ReeducatethepatientonDMandCKDasitrelatestotheprogressionofBK'sCKDstage3 toendstage. ReintroducethepatienttotheRenaldietandrestrictionsonsodium,potassium, phosphorous,andfluid.

RecommendthepatientforHemodialysis(3xwk,4hrs)andeducatethepatientonthe nutritionvariationsspecifictoHemodialysis;specificallyfluidrestriction,dryversuswet weight,electrolyterestrictions(K,Na,P),andhighproteinintake. Introducethepatienttophosphatebindersandstresstheimportanceofmaintainingher medicationsregimen;makingthepatientawareofherirondeficiencyanemia,CKDstage5 andelectrolyteimportance,andmortality. Goals: 1)Recommendthepatientkeepafood/fluid/weightjournalwhileadheringtotheRenal diet(aslongasthepatientisondialysis)untilthepatientisabletounconditionallyfollow thedietandmaintainelectrolyte/weight/proteinrelatedmarkerswithinnormalCKD ranges. 2)Maintainahighproteindietofatleast80gramsofproteinadaywhiledecreasing weightuntilaBMIofsub24isreachedtoimproveQOLandeffectivenessofHD. 3)Decreasefluidintaketo1.5LperdaytoimproveefficiencyofHDandcontrolweight gainbetweentreatments,whiledecreasingsoda(Tampico)andotherelectrolyterich fluids(wholemilkandorangejuice). Monitor/Evaluate: Meetwiththepatient3timesaweekbeforeHDappointmentsandmonitorthepatients adherencetotheRenaldietbythefood/fluid/weightjournalthepatientwillkeep. MonitorelectrolytelevelswhilepatientisonRenaldietandoverthecourseofHD treatmentspertainingtothekidneys(K,P,Na,andCa),protein/proteinwastemarkers (Albumin,BUN,Creatinine),andweightbeforeandafterHDtreatments. EvaluatePatientsadherencetothehighproteindietthroughjournalandtheuseofUUN inthenitrogenbalanceequation. Monitorandevaluatethepatientsanemicstatusoverthecourseoftreatment (Diet/HD/EPO/Iron)forimprovement(Hgb/Hct). PrintedName: Signature: Date/Time:

RenalDietPattern: 2gmSodium,2gmPotassium,1gmPhosphorous,and1.5LFluid Food # of Choices Meat (total of 8) - Animal Protein HBV (5) - Vegetarian Protein (3) Milk (1) Kcal Pro (g) Na (mg) K (mg) Phos (mg)

400 (80) 300 (100) 100

35 (7) 18 (6) 4.0

375 (75) 150 (50) 80

250 (50) 300 (100) 185

250 (50) 240 (40) 110

Bread/starch (8) Vegetable - Low (1) - Medium (1) - High (0) Fruit - Low (2) - Medium (1) - High (0) Fat (5) Extra (2) Fluids (1.5L) Choices: - use the milk option Total

800 (100)

16 (2)

640 (80)

360 (40)

240 (30)

50 50 0 150 (75) 75 225 (45) 120 (60)

2 2 2 (1) 1 trace trace

45 45 50 (25) 25 275(55) 30 (15)

75 150 100 (50) 160 50 (10) 40 (20)

50 50 50 50 25 (5) 10 (5)

2270

80

1715

1670

1075

Sources: NTP p. 537 (NRD Nutrition Composition of Foods for People on Dialysis) https://smartsite.ucdavis.edu/access/content/group/bc09b3bac6604648bcf5 e8ac1577a1f7/week%206/HandoutRenalDietExchanges.pdf FoodOptions:

8.Weightfluctuationsbetweenhemodialysissessionsisnormal.Hemodialysisisthe processofremovingfluidandwastefromthebloodasitisfilteredthroughanartificial kidney.Theartificialkidneyremoveswasteproductsandexcessfluidviadiffusion, ultrafiltration,andosmosis.Theartificialkidneydoesthejobofthehumankidney,butonly duringsessionsatalimitedrate.Typically,apatientdoesthreesessionsaweekthateach lastaboutfourhours,whereasanormalkidneyisworking24/7filteringtheblood.In betweensessions,thekidneyisnotabletofilterthebloodasefficientlyoratall,andallof theexcessfluidconsumedandwasteproductsofthebodyremain,resultinginadded weight.BecausethebodyretainsanyexcessfluidbetweenHDsessions,fluidandsodium restrictionsareimportanttoreduceHTN,edema,cardiacstress,SOB,etc. (http://www.davita.com/kidneydisease/dietandnutrition/dietbasics/fluidcontrolfor kidneydiseasepatientsondialysis/e/5321) 9.BKsproteinconsumptiononFebruary25threflected69.375gramsofproteiningested and71.25gramsonhersubsequentvisitFebruary27.BKisshyofconsumingtheamount ofproteinIrecommendedforher.Asanendstagerenaldiseasepatientonhemodialysis, BKrequiresahigherproteinintakeinordertoreplacetheproteinthatislostthrough dialysis.ItisnolongerrecommendedthatBKeatlowproteinbecausetheproteinwasteis beingremovedviadialysisandproteinisimportantinorderforBKnottolosemusclemass andmaintainherabilitytofightinfection.IhadrecommendedthatBKconsume80grams ofproteinormoreaday,roughly1.2g/kgBW/d.Thepatientisjustundermy recommendation,andinrealityIwouldlikehertobeconsuming80ormore. 10.Sodiuminthedietisimportant,itisawaytoregulatebloodpressureandvolume, transmitimpulse,andregulatethebodysacidbasebalance.However,inapatientwith CKD,consumingtoomuchcauseswaterretentionwithsuchcomplicationsasswelling, cardiacissues,andSOBduetothekidneysinabilitytoexcretetheexcesssodium.Witha patientlikeBK,onhemodialysis,alowsodiumdietisrecommended.Theuseofsalt substitutestomaintainalowsodiumintakewouldnotberecommendedbecausesomesalt substitutescontainpotassium,whichalsoneedstoberegulatedwithCKDpatients.The bestthingforBKtodowouldbetofindwaystoremovesodiumfromherdietasopposed tousingsaltsubstitutes,suchasusingspicestoboosttheflavoroffoodsorreadingfood labels. (http://www.davita.com/kidneydisease/dietandnutrition/dietbasics/sodiumand chronickidneydisease/e/5310)

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