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 Hypercholesterolemi

a 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 Dialysis Rec.

Calcium (mg/dL)

7.6 (L) 12-16 8.4-10.2

Potassium (mEq/L)

4.2 3.5-5.0 3.5-5.5

Phosphorus (mg/dL)

5.2 (H) 2.5-4.5 3.0-5.5

Sodium (mEq/L) 138 135-145 135-145

Hemoglobin (g/dL)

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 Opt: 4.0

Hb A1c (%) 6.2 (H) 4.4-6.1 Less than 7.0

Glucose (mg/dL)

172 (H) 70-105 80-180

URR (%) 76 - 65 or above

Creatinine (mg/dL)

4.38 (H) 0.8-1.6 2-15

Medications

Oral: Acetaminophen Nifedipine Clonidine Pravastatin Docusate Escitalopram Lisinopril Tramadol Tums

IV Epogen Hectoral

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, statin, reduce LDL and increase HDL

Alcohol, grapefruit products, other statins, 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

Energy (kcal/kg SBW) 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

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 Tomatoes Potatoes Bananas oranges

High Potassium Muscle weakness Bradycardia Cardiac arrest

Low Potassium Vomiting Diarrhea Hypotension

Phosphorus

Poorly dialyzed Phosphate binders

Renvela PhosLo Tums

High phosorus Calciphylaxis Hardened arteries Weak bones

Avoid high phosphorus foods Cheese Dairy Beans Nuts 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 (3rd 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.