Transcript ESRD Case Study Presentation

ERSD:
END STAGE
RENAL DISEASE
Kathryn Atwater
PVAMU Intern 2012-2013
Patient Background
71 year old
 Hispanic, white female
 Middle Class
 Separated
 Lives with daughter
 3 children
 History of tobacco use but no alcohol
 Stage 5 Renal Failure

General Health History


Sleeps well
Light physical activity
 Limited
due to walker
 Housework
 Tries to “walk” as much as possible

Lost 50 lb over past year
Food intake varies based on daughter

Alert with some memory loss

Recent Medical History

First hospitalized 1/30/13 for:
 Chronic
CHF exacerbation
 Anemia

2/3/13
 CVC
placed in right chest
 High creatinine finalized decision (5.06 mg/dL)
 Started hemodialysis immediately


No previous dialysis
Plans to get AVF as soon as possible
Past Medical History








Diabetes Mellitus
Hypertension
Congestive Heart Failure
Coronary Artery Disease
Hypercholesterolemia
Legally Blind
Glaucoma
Anemia


Heart Attack
Stroke
Family History

Mother:
 Heart
Attack
 Diabetes
 Kidney Cancer
 Colon Cancer
 Hypertension


No known medical history for father
Children in good health
Admission Values








Ht: 60”
Wt: 54.4 kg
Current Wt: 53.8
IBW: 54 kg
%IBW: 99.6%
BMI: 23.11
BP: 208/86
Minor Edema


Stable Weight Trend
No swallowing or GI
problems
Lab Values
Patient
Normal
7.6 (L)
12-16
8.4-10.2
4.2
3.5-5.0
3.5-5.5
5.2 (H)
2.5-4.5
3.0-5.5
138
135-145
9.8 (L)
12-16
10-12
Ferretin (ng/mL)
1217 (H)
3-151
200-500
PTH – Intact (pg/mL)
333 (H)
10-65
150-600
Albumin (g/dL)
3.4 (L)
3.5-5
Min: 3.5
Hb A1c (%)
6.2 (H)
4.4-6.1
Less than 7.0
Glucose (mg/dL)
172 (H)
70-105
80-180
76
-
4.38 (H)
0.8-1.6
Calcium (mg/dL)
Potassium (mEq/L)
Phosphorus (mg/dL)
Sodium (mEq/L)
Hemoglobin (g/dL)
URR (%)
Creatinine (mg/dL)
Dialysis Rec.
135-145
Opt: 4.0
65 or above
2-15
Medications
Oral:

IV
 Acetaminophen
 Epogen
 Nifedipine
 Hectoral
 Clonidine
 Pravastatin
 Docusate
 Escitalopram
 Lisinopril
 Tramadol
 Tums
Medication Descriptions
Medication
Use
Drug/Nutrient Interactions
Acetaminophen
Pain Reliever/Fever reducer
BP medication, cholesterol
medication, antibiotics, etc
Nifedipine
Reduce BP/reduce angina
grapefruit products
Clonidine
Reduce BP
alcohol
Primvastatin
HMG CoA reductase inhibitor, or, Alcohol, grapefruit
statin, reduce LDL and increase
products, other statins,
HDL
spironolactone,
Docusate
Stool softener
n/a
Escitalopram
Antidepressent
Alcohol; Cold or allergy
medicine, narcotics,
sleeping pills, muscle
relaxers
Medications Continued
Medication
Use
Drug/Nutrient Interactions
Lisinopril
Ace-Inhibitor/reduce BP/treat
CHF
Alcohol, salt substitutes,
other bp medications,
potassium supplements
Tramadol
Pain reliever
Alcohol, antidepressants
Clonidine
Reduce BP
alcohol
Tums
Phosphate binder, calcium
supplement, indigestion
n/a
Epogen
RBC production
n/a
Hectoral
Decrease PTH levels
Magnesium containing
antacids, digoxin
General Diet History







Good appetite
Lost 50 lbs in past year
Small portions
Tries to “eat healthy, but
depends on my daughter”
3 meals a day
1 snack
Says new renal diet is “tricky”
but she’s trying
24-hr Recall




Breakfast: 2 eggs over easy, 1 piece of white toast
& 1 tsp butter
Lunch: Pepper chicken with snap peas, red
peppers, and carrots, ½ cup white rice
Dinner: None (usually eats whatever daughter picks
up after work)
Snack: 1 Mexican Cookie and a half of an apple
Dialysis Prescription








Type: Hemodialysis
Days: M-W-F
Treatment Length: 2.5 hr
BFR: 350 mL/min
Dialysate Flow Rate: 800 mL/min
Access: CVC catheter – Jugular (Right)
Average Fluid Gain: 1.6 kg
EDW: 52 kg
Patient Estimated Needs






Kcal: 1550-1600
Protein: 60 g
Sodium: 2000 mg
Potassium: 2000 mg
Phosphorus: 800 mg
Fluid: 1000 mL
Diet Prescription

Renal Diet
 Low
Potassium
 Low Phosphorus
 High Protein


Carbohydrate Controlled
Low Fluid
Monitoring & Evaluation






Start taking Tums as a phosphate binder
Start Hectoral to decrease PTH levels
Increase Epogen to increase hemoglobin
Get fistula as soon as possible
Patient eager to participate actively
Prognosis:
 GOOD!
ESRD: What is it?


End Stage Renal Disease
Stage 5 kidney disease
 Kidneys
 stop
working i.e. kidney failure
 <15% kidney function
 PERMANENT
 Need


a transplant or dialysis to live
No cure
Goal of treatment: Slow progression
ESRD: Etiology & Pathophysiology


Progression of CKD
Main causes:
 Diabetes
 Hypertension



Kidney Failure=DEADLY
GFR <15 mL/min
Dialysis or Transplant
required
ESRD: Diagnosis
GFR rate calculation
 Urine Test
 Blood Test
 MRI
 Biopsy

ESRD: Signs & Symptoms








General “ill” feeling
Itchy skin
Dry skin
Loss of appetite
Nausea
Edema
Muscle-twitching &
cramps
Headaches


Decreased urine output
Poor concentration
ESRD: Treatment



Hemodialysis
Peritoneal Dialysis
Transplant
 Not
a cure
 Last about 5-10 years
 Strict guidelines
Treatment: Hemodialyis

Hemodialysis
 Filter
blood
 Access Points
 Clinic
 Strict Diet
Treatment: Peritoneal Dialysis

Peritoneal Dialysis
 Filter
through peritoneum
 Home
 Through abdomen
 Less Strict Diet
ESRD: Common Medicines






Binders
Hectoral
Sensipar
Epogen
Iron
Calcitriol
Renal Diet
Hemodialysis
Peritoneal Dialysis
30-35
30-35
Protein (g/kg SBW)
1.2
1.2 & higher
Phosphorus (mg/kg
SBW)
800-1000
800-1000
Potassium (mg/d)
2000-3000
3000-4000
Sodium (mg/d)
2000-3000
2000-3000
Fluid (mL/d)
750-1000
2000
Energy (kcal/kg
SBW)
Protein



Protein loss with dialysis
Affected by infection &
trauma
Essential for:
 Growth
& development
 Prevent infection
 Healing
 Tissue
 Wound

HBV sources
 Meat
 Fish
 Poultry

Protein Supplement
Potassium

Limit high potassium
foods
Low Potassium
 Vomiting
 Tomatoes
 Diarrhea
 Potatoes
 Hypotension
 Bananas
 oranges


High Potassium
 Muscle
weakness
 Bradycardia
 Cardiac arrest
Phosphorus



Poorly dialyzed
Phosphate binders

Avoid high phosphorus
foods
 Renvela
 Cheese
 PhosLo
 Dairy
 Tums
 Beans
High phosorus
 Nuts
 Calciphylaxis
 Hardened
arteries
 Weak bones
 cola
Fluid



Fluid restriction
Approx 48 oz. per day
Based on:
 Urine
output
 Interdialytic weight gains

Excess fluid:
 Rapid
weight gain
 High blood pressure
 Edema
 Poor appetite
Physical Activity


Difficult for most
Benefits
 Stimulate
appetite & circulation
 Improve cardiovascular risk factors
 Hypertension
 Hyperlipidemia
 Diabetes
 Obesity
 Enhance
sense of well-being
PES Statement

Limited kidney function related to end stage renal
disease as evidenced by low serum calcium,
anemia, low serum protein, high serum phosphorus,
high PTH, and high serum creatinine levels.
Follow-up






Hemoglobin went up to 10.9, reduced Epogen dose
Fistula placed in left arm on March 14th
Understands disease & reason for treatment
Adjusting slowly but well
As of 3/15 moved out of daughters home
Patient says, “Will make it!”
Summary



ESRD is DEADLY if not treated properly.
Diet is the key component to keeping person in
optimal health
Prognosis:
 Good
if sticks to plan

QUESTIONS?
References












McMann, L (ed): Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease (3 rd ed).
New York, National Kidney Foundation, 2002.
"Kidney Dialysis Basics - DaVita." Kidney Dialysis Basics - DaVita. DaVita Inc., 2013.
<http://www.davita.com/kidney-disease/dialysis/the-basics>. 17 Mar. 2013.
Bynam-Gray, L and Weisen, K (eds). A Clinical Guide to Nutrition Care in Kidney Disease. American
Dietetic Association and National Kidney Foundation, 2004.
Drug Information Online: Drugs.com. 2013-2014. < http://www.drugs.com>. 19 March 2013
K/DOQI: Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. Am J Kidney Dis 35(6), Suppl 2,
2000.
Kopple JD, Massry SG (eds): Nutritional Management of Renal Disease. Baltimore, Williams & Wilkins,
1997.
National Renal Diet, 2nd Ed. American Dietetic Association, 2002.
Pritchett, E. Medical Nutrition Therapy (MNT) for Chronic Kidney Disease. Real Nutrition Forum, the
American Dietetic ASSN, Vol 22, No 1, Winter 2003.
Staff, Mayo Clinic. "Definition." Mayo Clinic. Mayo Foundation for Medical Education and Research, 11 Dec.
2010. <http://www.mayoclinic.com/health/hemodialysis/MY00281>. 18 Mar. 2013.
Stover, J (ed). A Clinical Guide to Nutrition Care in End-Stage Renal Disease. American Dietetic
Association, 1994.
Wiggins, K. Nutrition Care of Renal Patients, 3rd Ed. The American Dietetic Association, 2001.
Zieve, David, MD, and Herbert Lin, MD. "End-stage Kidney Disease." U.S National Library of Medicine. U.S.
National Library of Medicine, 21 Sept. 2011.
<http://www.nlm.nih.gov/medlineplus/ency/article/000500.htm>. 16 Mar. 2013.