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CaseStudy#3Renal Interpretation CaseBasedInterpretation Reference withCKDranges(NTPp.532 533) 1529mL/min Pocket Kidneydamage:severe Reference reductionofGFR pg.109 (recommendationforkidney replacementdialysis)
GFR
15mL/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
142mEq/L
WNL
5.7mEq/L
Serum Albumin
2.8g/dL
3.55.0g/dL
Hgb/Hct
11.5g/dL/ 28%
Botharetoolowand1012g/dL/3336% Pocket indicateanemia Renalfailure/renalartery Referencep. stenosis,uremia. 77,112 (anemiaorinadequateESA) Low Lowironstoreslinkedto Anemia,nephrosis anemia. Pocket Reference p.81
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
3.04.5mg/dL
Toohigh
PTH
100pg/mL
1065pg/mL
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
Drugs:
Purpose:
NutrientInteractions:
SideEffects:
Metformin
Oralhypoglycemic
AvoidAlcohol
Lasix
Treatmentforedema, loopdiuretic
Vasotec
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)
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 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)