Theresa Price 4/16/14

Patient Background

Primary Disease Pathophysiology

Abnormal Labs Medications

MNT
ADIME

 C. R.
51 y.o. black female Admission Date:

3/9/2007 Present HD- M, W, & F Recent hospital visit for heart palpitations Hemodialysis for ESRD

 Primary Dx:
Hypertensive Kidney Disease with ESRD on

Hemodialysis
Secondary Dx:
HTN CHF CAD A.Fib

 Pt is single and son lives with her

Unemployed
Family Medical Hx:
Father: Kidney disease and failure, HTN. Mother: HTN, Thyroid disease, Thrombophlembitis,

DM, Clotting disorder. Brother: Kidney disease and failure

 No history of smoking or alcohol use

Social Support: Family (son)

Allergies include:
Keflet, Levaquin, Vancomycin, Allopurinol,

Clindamycin/Lincomycin, Latex.

Hypertensive Kidney Disease with ESRD 2. HTN 3. CHF 4. CAD

1.

Hypertensive Kidney Disease: ESRD

 High blood pressure damages the blood vessels in the

kidneys, reducing their ability to work properly. Result from:

Uncontrolled HTN

Symptoms:
Typically no symptoms with HTN or early stages of

kidney failure. May have edema. Further kidney failures symptoms include: appetite loss, N/V, drowsiness, dry skin, muscle cramps, and weight loss

 Hemodialysis, Peritoneal Dialysis, or Transplant

In HD a machine filters the blood, removes waste and

clean blood is circulated back into body Performed at unit 3-4 times a week and can last 3-5 hours each time In PD dialysate fluid enters peritoneal cavity, by osmosis the waste travels to dialysate, then dialysate fluid is drained and replaced with new fluid. Performed at home and done overnight

 Transplant
Common transplant surgery
Dialysis is discontinued The new kidney is placed in the lower abdomen and

diseased kidney remains (unless otherwise referred) Immunosuppressant medications are used to avoid rejection

 HTN
Connects all diagnoses Damages nephrons and arteries, while narrowing blood

vessels throughout the body

A. Fib
Common arrhythmia, due to less than sufficient electrical

signals in the heart

CHF
Heart muscles become stiff and can not fill up and pump

throughout the body efficiently

CAD
Narrowing of blood vessels

 Renal Select (Low K, Low Na, High Pro)

Calculated needs:
Energy: 2070-2415kcal (30-35kcal/kg EDW) Protein: 82.8g (1.2g/kg) Fluid:1200ml Pt reported very good appetite

 Typically use 30-35kcal/kg 1,

2

Protein needs are 1.2g/kg

with 50% from HBV 1, 2 Restricted fluid intakes are generally 1.2L/day 1, 3 Modify eating too much high K foods to reduce K lab value

1 (Nelms, Suchar, & Long, 2007)

2 (Wolfson, 1999) 3 (Davita, 2014)

Nutrition Assessment

 Ht: 61in

Wt:153lb
EDW: 152lb IBW: 105lb

ABW: 117lb
Intra-dialytic weight gain: 4lb BMI: 28.7 (Overweight)

No present edema

Lab Measure

Pt Value

Normal Renal Value

>65%

Cause

Urea Reduction Ratio Kt/V Calcium Phosphorus Ca:Phos Product Parathyroid

78.85%

Normal

1.86 9.0mg/dL 4.2mg/dL 38mg/dL 44.5

>1.5 8.5-9.5mg/dL 3.5-5.5mg/dL <55mg/dL 150-300

Normal Normal Normal Normal Low due to medication.

Hormone-Intact

Lab Measure

Pt Value

Normal Renal Value

<7.0% 140-199mg/dL <100mg/dL 41-75mg/dL 35-159mg/dL >4.0g/L 3.5-5.0mEq/L 1.5-2.5mg/dL

Cause

HbA1c Cholesterol LDL-Cholesterol HDL-Cholesterol Triglyceride Albumin-Green Potassium Magnesium

n/a 122mg/dL 55mg/dL 47mg/dL 98mg/dL 4.2g/L 5.1mEq/L 2.2mg/dL

n/a Low due to poor diet. Normal Normal Normal Normal High due to diet Normal

Medication Cinacalcet (Sensipar) Metoprolol Renvela Coumadin Epoeitin Alfa Reduces PTH

Use Beta Blocker, Lowers BP Phosphate Binder, Reduces Phosphorus level Blood thinner due to heart conditions Stimulate RBC production

Breakfast
Coffee (8oz) Oatmeal w/Raisins (1 instant packet w/ oz)

Lunch
Grilled Chicken (Med. Breast) Salad: Lettuce, Tomato, Cucumber, Onions, Carrots (2 c total) Ranch Dressing (3 tbsp)

Snack

Dinner

Peanut Butter Wendys Plain Burger Crackers (6) (2 buns, 1 patty) th Apple Pie (1/8 of the Doritos (1.5oz) pie)

2 Toast w/ Butter (White w/ 1 tbsp)

Water (8oz)

Water (8oz) * Lunch/Dinner

Nutrient Total calories Protein CHO Fiber Total Fat Sat fat Ca

Amount 1791kcal 62g 14%, 207g 17g 41%, 82g 12%, 24g 467mg

K Na
P Fluid

1831mg 2434mg
813mg 720ml

 Assessment: previously discussed

Nutrition Diagnoses: Excessive Potassium intake RT physiological causes decreasing nutrient needs due to chronic renal disease AEB Potassium level of 5.1mg/dL and heart palpitations.
Predicted excessive nutrient intake of Vitamin D (Zemplar)

RT recent high dosage due to very high PTH values and needed Vitamin D to decrease levels AEB a large reduction in PTH values since labs last taken.

 Intervention:
Educate pt on high and low K foods
Provide handout with high and low K foods Provide dialysis friendly grocery list and cook book Discontinue Zemplar.

 Reported good appetite

Discussed high and low K foods with handout

Likes potatoes Provided grocery list and cook book

 Monitoring:
Monitor lab values

Evaluating:
PTH will be WNL K will be WNL Pt will have a better

understanding of foods with higher and lower amounts of K.

700

600

500

400 PTH 300

200

100

0 September December April

5
4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 October November December April

Albumin

150

145

140

135

130

Chol

125

120

115

110 December '12 December '13 December '14

K Lab Value
6

Column2

0 January February March April

 Pt reported to be good with diet compliance

Laboratory values are generally WNL

Guarded prognosis due to ESRD Kidney transplant on hold due to heart conditions

 American Heart Association. (2012). What are the symptoms of

high blood pressure? Retrieved 8 April 2014, from http://www.heart.org/HEARTORG/Conditions/HighBloodPress ure/SymptomsDiagnosisMonitoringofHighBloodPressure/What -are-the-Symptoms-of-High-BloodPressure_UCM_301871_Article.jsp American Kidney Fund. (2014). End stage renal disease. Retrieved 7 April 2014, from http://www.kidneyfund.org/kidney-health/kidney-failure/endstage-renal-disease.html Blood Pressure Association. (2008). What high blood pressure (hypertension) can do. Retrieved 8 April 2014, from http://www.bloodpressureuk.org/BloodPressureandyou/Yourb ody

 Davita. (2014). Potassium and chronic kidney disease. Retrieved 8

April 2014, from http://www.davita.com/education/article.cfm?educationMainFolder= diet-and-nutrition&category=diet-basics&articleTitle=potassiumand-chronic-kidney-disease&articleID=5308 Hedayati, S. S. & Szczech, L. A. (2004). The evaluation of underlying cardiovascular disease among patients with end-stage renal disease. Advances in Chronic Kidney Disease, 11, 246-253. Doi: 10.1053/j.arrt.2004.04.011 Horl, W. H. (2010). Hypertension in end-stage renal disease: Different measures and their prognostic significance. Nephrology Dialysis Transplant, 25, 3161-3166. Doi: 10.1093/ndt/gfq428 Medline Plus. (2011). Kidney transplant. Retrieved 8 April 2014, from http://www.nlm.nih.gov/medlineplus/ency/article/003005.htm

 Murtagh, F. E. M., Addington-Hall, J., & Higginson, I. J.

(2007). The prevalence of symptoms in end-stage renal disease: A systematic review. Advances in Chronic Kidney Disease, 14, 82-99 doi: 10.1053/j.ackd.2006.10.001 National Kidney Foundation. (2014). Kidney disease: Causes. Retrieved 7 April 2014, from (http://www.kidney.org/atoz/content/kidneydiscauses.cfm

 Owens, S. Personal communication. March 26, 2014.

Pronsky, Z. M. (2008). Food medication interactions (15th

ed.) Birchrunville, Penn.: Food-Medication Interactions. Wolfson, M. (1999). Management of protein and energy intake in dialysis patients. Journal of American Society of Nephrology, 10, 2244-2247. Retrieved from http://jasn.asnjournals.org/content/10/10/2244.long

Questions?