ersd: end stage renal disease kathryn atwater pvamu intern 2012-2013
TRANSCRIPT
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ERSD: END STAGE RENAL DISEASE
Kathryn Atwater
PVAMU Intern 2012-2013
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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
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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
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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
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Past Medical History
Diabetes Mellitus Hypertension Congestive Heart
Failure Coronary Artery
Disease Hypercholesterolemi
a Legally Blind Glaucoma
Anemia
Heart Attack Stroke
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Family History
Mother: Heart Attack Diabetes Kidney Cancer Colon Cancer Hypertension
No known medical history for father Children in good health
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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
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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
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Medications
Oral: Acetaminophen Nifedipine Clonidine Pravastatin Docusate Escitalopram Lisinopril Tramadol Tums
IV Epogen Hectoral
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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
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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
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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
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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
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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
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Patient Estimated Needs
Kcal: 1550-1600 Protein: 60 g Sodium: 2000 mg Potassium: 2000 mg Phosphorus: 800 mg Fluid: 1000 mL
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Diet Prescription
Renal Diet Low Potassium Low Phosphorus High Protein
Carbohydrate Controlled Low Fluid
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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!
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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
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ESRD: Etiology & Pathophysiology
Progression of CKD Main causes:
Diabetes Hypertension
Kidney Failure=DEADLY
GFR <15 mL/min Dialysis or
Transplant required
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ESRD: Diagnosis
GFR rate calculation Urine Test Blood Test MRI Biopsy
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ESRD: Signs & Symptoms
General “ill” feeling Itchy skin Dry skin Loss of appetite Nausea Edema Muscle-twitching &
cramps Headaches
Decreased urine output
Poor concentration
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ESRD: Treatment
Hemodialysis Peritoneal Dialysis Transplant
Not a cure Last about 5-10
years Strict guidelines
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Treatment: Hemodialyis
Hemodialysis Filter blood Access Points Clinic Strict Diet
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Treatment: Peritoneal Dialysis
Peritoneal Dialysis Filter through peritoneum Home Through abdomen Less Strict Diet
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ESRD: Common Medicines
Binders Hectoral Sensipar Epogen Iron Calcitriol
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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
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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
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Potassium
Limit high potassium foods Tomatoes Potatoes Bananas oranges
High Potassium Muscle weakness Bradycardia Cardiac arrest
Low Potassium Vomiting Diarrhea Hypotension
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Phosphorus
Poorly dialyzed Phosphate binders
Renvela PhosLo Tums
High phosorus Calciphylaxis Hardened arteries Weak bones
Avoid high phosphorus foods Cheese Dairy Beans Nuts cola
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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
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Physical Activity
Difficult for most Benefits
Stimulate appetite & circulation Improve cardiovascular risk factors
Hypertension Hyperlipidemia Diabetes Obesity
Enhance sense of well-being
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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.
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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!”
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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?
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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.