Transcript Renal Mini Case Study

Renal Mini Case Study
By Melissa Jakubowski
Patient Information
 Initials: M.H.
 Female
 72 years old
 Full code
 NKFA
 1st date of chronic HD Tx: 8/10/2010
 1st date of Tx at Fresenius: 8/20/2010
Socioeconomic/Family Status
 Retired
 Lives at home with husband
 Husband prepares meals
 Denies alcohol/illicit drug use
 H/o of smoking, quit 35 years ago
Anthropometric Data
 Height: 62”
 BMI: 22.0 (LBW)
 Weights:
 IBW: 131-158 lbs.
 EDW: 54.50kg (119.9 lbs.)
 91.5% IBW
 Pre-weight: 55.80kg
 IDWG: 1.3kg
(122.8 lbs.)
 Post-weight: 54.30kg
(119.5 lbs.)
• No recent weight
gain/loss
Interdialytic Weight Gain
• IDWG: 1.3kg
 IDWG Recommendations:
 <3kg on weekdays
 <4kg on weekends
Or
 <5% of EDW
 Equals 2.7kg for this
patient
Biochemical Data
Lab Value
CurrentValue
Hemoglobin
Hematocrit
Potassium
BUN
Creatinine
Calcium
Corrected Calcium
Phosphorus
Albumin
Parathyroid Hormone (PTH)
10.9
34.9 ↓
4.6
65
5.8
9.4
9.8 ↑
4.4
3.5 ↓
189.1
Abnormal Lab Values
Lab Value
Current Value
Nutritional Significance
Hematocrit
34.9 ↓
CKD → decreased EPO
Corrected Calcium
9.8 ↑
Low albumin
Albumin
3.5 ↓
???
Serum Albumin History
4
Albumin (g/dl)
3.9
3.8
3.7
3.6
3.5
3.4
3.3
3.2
Dec
Jan
Feb
Mar
Apr
May
Admitting Diagnosis
Diagnosis
Pathophysiology
 ESRD (on HD) secondary
 Hypertensive nephropathy
HTN
& nephrosclerosis
 Lupus (SLE)
 Kidney mass
Past Medical History
PMH
Pathophysiology
CAD
HTN, h/o smoking, older age, dietary
habits
MI
CAD
PTCA
Surgical treatment of CAD
HTN
High sodium diet, h/o smoking, CKD
Lupus
Unknown; possibly hereditary
2cm Right Kidney Mass
H/o smoking, HTN
Contrast neuropathy
Renal insufficiency, specifically ↑ creatinine
HD Access
Currently
Infection
Left AV
Graft
Cath
Placements
Temporary
Right
AV fistula
Medications
Medication
Indication
Aspirin (acetylsalicylic acid)
Prevention of blood clots
Pain (neuropathy) & inflammation (Lupus)
Lopressor (metoprolol)
HTN
Prednisone (corticosteroid)
Lupus
Zocor (simvastatin)
Hyperlipidemia
Renagel (sevelamer HCl)
ESRD re: serum P levels
Fish oil (omega-3 fatty acids)
Hyperlipidemia
Nexium (esomeprazole)
↓s risk for gastric/duodenal ulcers
Prednisone Side Effects
 ↑ N urinary excretion
 Induces negative nitrogen balance
 Pathophysiology of low albumin
Abnormal Lab Values
Lab Value
Current Value
Nutritional Significance
Hematocrit
Corrected Calcium
Albumin
34.9 ↓
9.8 ↑
3.5 ↓
CKD → decreased EPO
Low albumin
Prednisone
Zocor Patient Education
 Avoid/limit grapefruit and
other citrus fruits which
inhibit the liver enzymes
responsible for
metabolizing Zocor
Supplements
 Dialyvite: Renal MVI,
primarily containing Bcomplex vitamins, folic
acid, essential minerals
 Vitamin C: limited to 60100mg/day to avoid
formation of calcium
oxalate kidney stones
 Protein supplement
3x/week (Nepro or Zone
Bar)
Nutrition Needs
Calorie
Protein
 30-35kcal/kg: 1600-1900
 1.2-1.3g/kg: 65-71g
 Harris-Benedict: 1500
 Mifflin-St. Jeor: 1000
Fluids
 Fluid restriction of 1500mL (standard restriction for HD patients
that produce < 1 L of urine/day)
 1500mL = 50 fl. oz.
Current Dietary Recommendations
 ↑ protein diet (65-71 g/day)
 P restriction (800-1200 mg/day)
 K restriction (2000 mg/day)
 Na restriction (1500-2000 mg/day)
 Fluid restriction (1500 mL/day)
PES Statement
 Increased protein, calorie, and vitamin & mineral needs
related to ESRD on HD as evidenced by LBW (BMI = 22)
and low serum albumin (3.5g/dl)
Interventions
 Nutrition Rx: continue as recommended
 Protein supplement: continue as ordered
 Dialyvite & P-binder: continue as prescribed
 Encourage intake of high biological value (HBV) protein
foods (eggs, meat, poultry, fish)
 Continued HD diet education
Goals
To be achieved by next follow-up (48 hours):
 Lab (alb): to trend toward standard
 EDW: stable
 IDWG per standards
 Pt. to report:
 Dietary adherence to nutrition rx
 100% supplement intake
 Oral intake amount per her normal; good appetite
 MVI and P-binder taken daily as prescribed
Monitoring/Evaluation
 Labs, especially K, P, Ca, Alb, PTH
 Pt. self-report: oral supplementation intake, oral
intake/appetite, and GI Sx
 Level of the knowledge: continued verbalization of nutrition
rx
 Weights (EDW, pre-weight, post-weight) to determine
IDWG and assess adherence to fluid restriction and dialysis
sufficiency
 Change in medical history, especially regarding the kidney
mass
Questions???