Acute Kidney Injury & Type 1 Diabetes

Annie Gallagher
Dietetic Intern University of Maryland College Park February 18 2014

Objectives
To Understand Acute Kidney Injury, its three categories, and its diagnostic criteria To receive an overview of the hospital course of a patient with Acute Kidney Injury and underlying Type 1 Diabetes To receive an overview of the Nutrition Interventions of a patient with Acute Kidney Injury and underlying Type 1 Diabetes. To understand treatment of Acute Kidney Injury in a Critical Care setting.

Acute Kidney Injury (AKI)

Occurs in approximately 20% of patients admitted to Intensive Care Unit Often a Complication of
Sepsis Trauma Multiple Organ Failure

Poor Prognosis
Mortality ranges 40% - 80%

Acute Kidney Injury (AKI)

The complex process of the progressive diminution of kidney function 3 categories
Prerenal
Underlying condition denies kidney blood flow

Intrarenal
Part of kidney is damaged

Postrenal
Obstruction of urine flow

Acute Kidney Injury (AKI)

Diagnostic Criteria
An abrupt (within 48 hrs) reduction in kidney function currently defined as an absolute increase in serum creatinine of > 0.3 mg/dl, a 50% increase or reduction in urine output
- Acute Kidney Injury Network

Acute Kidney Injury

Nutritional Imbalances
Rapid Decrease in Urine output Acidosis Electrolyte Imbalances Fluid Disturbances Impaired Glucose Utilization Protein Catabolism Accumulation of metabolic waste products

DH
52 yo Female Ht: 137.2 cm Wt: 98.8 kg Married, no children Insurance: Medicare, United America Past Medical History
Acute Renal Failure Rheumatoid Arthritis Type 1 Diabetes Metabolic Syndrome Turner Syndrome Chronic Obstructive Pulmonary Disease Hypertension

DH Hospital Course
Admitted to ED with weakness, falls and tremors Diagnosis of Acute Kidney Injury secondary to hypotension and dehydration Blood Pressure (BP) 70/39 Diagnostic Tests
Urinalysis Positive for Urinary Tract Infection Basic Metabolic Panel Consistent with AKI

DH Hospital Course
Day 1 9/30/2013 IV fluids and D50. Insertion of right femoral line. Day 2 Additional IV fluids, BP increased. Insulin pump stopped, began treating diabetes with intravenous drip insulin Day 3 Nephrology consult confirmed AKI. Continued hydration with monitored output. Edema noted. Insulin pump restarted. Patient transferred to medical bed.

DH Hospital Course
Day 4 Patient complaints of bloating, MD noted 1+ pitting edema in lower extremities. Plan to re-start Lasix - Nutrition Consult Ordered Day 5 Critical Care Outreach Team (CCOT) called due to patients hypoglycemia D50 bolus, short term discontinuation of insulin pump Day 6 MD advised discharge to rehabilitation facility, however, patient refused. Patient discharged home under care of husband and mother.

Nutrition Assessment (NA) 10/3

Nutrition Consult ordered Day 4 due to extreme fluctuations of blood glucose levels, in addition to morbid obesity DH reported previous medical nutrition therapy education for carbohydrate counting and diabetes management. Reported fingerstick range of 150 240 mg/dl prior to admission

Nutrition Assessment Diet History

DH reported decreased appetite and weight loss prior to admission. Also had difficulty preparing and consuming meals Follows a vegetarian diet Evening meal consists of starchy, combination foods Manages her diabetes with insulin pump fingersticks at least 4 times per day.

Nutrition Assessment
Visited patient while eating lunch
Salad Grilled cheese 4 oz cranberry juice

DH stated lunch was 47g CHO which she entered into her insulin pump

In-Patient Medications
Aspirin, Atorvastatin, Clopidogrel, Dextrose 50%, Escitalopram (Lexapro), Fluticasone, Furosemide, Gabapentine, Heparin, Insulin Aspart (Novolog), Insulin Glargine (Lantus), Isosorbide, Levalbuterol HCl (Xopenex), Metroprolol, Montelukast Sodi (Singulair), Nystatin, Pantoprazole, Prednisone, Sulfasalazine, Synthroid 100 MCG, Tiotropium Bromi (spiriva), Tramadol HCl (ultram), Trazodone, Vitamin D

Laboratory Values
Lab Na K Cl CO2 Anion Gap Glucose BUN Creat Ca AST ALT 10/03/2013 140 4.1 105 27 8 122 21 1.4 8.2

Estimated Nutrition Needs

Height 137.2 cm 4 ft 6 in Source Facility Standards Weight 98.8 kg 217.4 lb BMI IBW 40 kg 88 lbs Protein Requirements 1.0 - 1.2 g/kg/d ABW 54 - 65 g/d n/a 0.8 - 1.2 g/kg/ d (without dialysis) 80 - 118 g/d %IBW 247% ABW 54.7kg 120 lbs 52.4 Morbid obesity Kcal Requirements

Fluid Requirements 30 - 35 ml/kg/d ABW 1600-1900 ml/d n/a 2000 - 2500 ml/d 500 cc + urine output

EAL Nutrition Care Manual (NCM)

Mifflin x 1.2 - 500 kcal/day for 1 lb wt loss/ week. 1200 kcal/day n/a 25-35 kcal/day 2450-3430 kcal/d

Nutrition Diagnosis
NC-3.3 Obesity related to excessive energy intake & physical inactivity, as evidenced by metabolic syndrome and BMI 52.3

Nutrition Intervention
E-1 Nutrition Education. Goal - pt will continue to demonstrate understanding of CHO counting. Reinforce the need for patient to do finger sticks before programming insulin pump. E-2 Pt will show adequate understanding of carbohydrate counting in both meal selection and programming of insulin pump.

Nutrition Intervention
RC 1.3 Refer pt to outpatient diabetes center for further training after discharge to review coordination of finger sticks, insulin infusion and oral intake. ND-1.2 Protein-modified diet. Goal - pt will adhere to renal diet order

Nutrition Assessment - 10/4

Critical Care Outreach Team responded to call in early a.m. for patient Glucose of 33 mg/dL Visited patient to inquire
Patient miscounted CHO content of meals
Patient recalled dinner: vegetable lasagna, carrots, sugarfree pudding, and juice. Patient counted 80g CHO Recalled breakfast: 2 pancakes with syrup, rice krispies, skim milk; pt stated meal was 75g CHO.

Patient stated she would like help in CHO counting

Nutrition Diagnosis 10/4

NB-1.1 Knowledge deficit related to lack of complete carbohydrate counting information and understanding of correct insulin programming relative to carbohydrate intake, as evidenced by pt's overestimation of carbohydrates in food consumption and excessive concern with potential high blood sugar.

Nutrition Intervention 10/4

E-1 Nutrition Education - diabetes management through CHO counting. Nutrition therapy for AKI. Provide resources for patient to use upon discharge RC 1.3 - refer pt to outpatient diabetes center for further training after discharge to review coordination of finger sticks, insulin infusion and oral intake. RC 1.4 - Provide Education of Carbohydrate Counting in relation to programming of insulin pump to current RN and floor staff assigned to DH's current care.

Case Discussion
Patients with complete or near-complete renal function recovery are at greater risk for developing chronic kidney disease Increased length of stay, mortality risk, and associated costs of AKI are directly related to increases in serum creatinine values

Case Discussion
Side effects of AKI include a decrease in urine output, acidosis, increased blood glucose values, electrolyte imbalances, and fluid disturbances Treatment of AKI includes the use of fluids, the avoidance of diuretics and nephrotoxins, and the close monitoring of urinary output

Case Discussion
Risk for kidney injury increases with the presence of other diseases, specifically diabetes Diabetes is associated with kidney injury and failure due to prolonged high blood-glucose causing injury to the filtration function of kidneys

Case Discussion
There is no evidence indicating nutrition intervention improves recovery of renal function. Management of AKI includes
Treating underlying cause Preventing complications Correcting fluid, electrolyte, and uremic abnormalities

In this case study, treating underlying causes was key

Unanswered Questions. . .
How was the patient discharged from rehabilitation center but admitted to ED needing 3+ Liters of fluids after 4 days? UTI diagnosed but localized and not associated with sepsis wouldnt this normally not cause such a decrease in fluid status? Was this patient a good candidate for self monitoring with insulin pump?

Conclusion
This case study supports the importance of nutrition education to encourage patients to willfully adhere to recommendations The importance of fully assessing a patient to identify all contributing factors related to a patient's illness

References
Palevsky P, Liu KD, Brophy PD, et al. KDOQI Commentary on the 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury. American Journal of Kidney Disease. 2013; 61 (5): 649-672. The Academy of Nutrition and Dietetics. Nutrition Care Manual - Acute Renal Failure. 2013. Accessed 23 November 2013. <http://www.nutritioncaremanual.org/topic.cfm?ncm_category_id=1&lv1=5537&lv2=255347&n cm_toc_id=23011&ncm_heading=Nutrition%20Care#>. The University of Maryland Medical Center. Medical Reference Guise. Acute Kidney Failure. 2011. Accessed 8 December 2013. <http://umm.edu/health/medical/ency/articles/acute-kidneyfailure>. Workeneh B, Agraharkar M, Gupta R, et al. Medscape. Acute Kidney Injruy. 2013. Accessed 8 December 2013. <http://emedicine.medscape.com/article/243492-treatment>. 15 Sybert VP and McCauley E. Turner's Syndrome. The New England Journal of Medicine. 2004; 135 (12): 1227-38. Chertow GM, Burdick E, Honour M, et al. Acute Kidney Injury, Mortality, Length of Stay, and Costs in Hospitalized Patients. Journal of the American Society of Nephrology. 2005; 16; 3365-3370. Bristol-Myers Squibb. AtraZeneca Pharmaceuticals. Onglyza. 2013. Accessed 31 December 2013. <http://www.onglyza.com/index.aspx?TC=13587&utm_source=google&utm_medium=cpc&utm _campaign=decisionong&utm_term=onglyza&utm_content=dbrandedbrand_textad_Home_tex t_tc13587> 16 Kidney Disease of Diabetes. National Institute of Diabetes and Digestive and Kidney Diseases; National Institute of Health. 2013. 13; 3925.

Questions?