ERSD END STAGE RENAL DISEASE Kathryn Atwater PVAMU

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/d. L) � Started hemodialysis immediately No previous dialysis Plans to get AVF as soon as possible

Past Medical History Diabetes Mellitus Heart Attack Hypertension Stroke Congestive Heart Failure Coronary Artery Disease Hypercholesterolemia Legally Blind Glaucoma Anemia

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/m. L) 1217 (H) 3 -151 200 -500 PTH – Intact (pg/m. L) 333 (H) 10 -65 150 -600 Albumin (g/d. L) 3. 4 (L) 3. 5 -5 Min: 3. 5 4. 0 Hb A 1 c (%) 6. 2 (H) 4. 4 -6. 1 Calcium (mg/d. L) Potassium (m. Eq/L) Phosphorus (mg/d. L) Sodium (m. Eq/L) Hemoglobin (g/d. L) Dialysis Rec. Opt: Less than 7. 0

Medications Oral: IV � Acetaminophen � Epogen � Nifedipine � Hectoral � Clonidine � Pravastatin � Docusate � Escitalopram � Lisinopril � Tramadol � Tums

Medication Descriptions Medication Use Drug/Nutrient Interactions Acetaminophe Pain Reliever/Fever reducer n BP medication, cholesterol medication, antibiotics, etc Nifedipine Reduce BP/reduce angina grapefruit products Clonidine Reduce BP alcohol Primvastatin HMG Co. A reductase inhibitor, Alcohol, grapefruit or, statin, reduce LDL and products, other statins, increase HDL spironolactone, Docusate Stool softener n/a Escitalopram Antidepressent Alcohol; Cold or allergy medicine, narcotics, sleeping pills, muscle

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 m. L/min Dialysate Flow Rate: 800 m. L/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 m. L

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 m. L/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 � 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 Protein (g/kg SBW) 1. 2 & higher Phosphorus (mg/kg SBW) 800 -1000 Potassium (mg/d) 2000 -3000 -4000 Sodium (mg/d) 2000 -3000 Fluid (m. L/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 � Phos. Lo � Dairy � Tums � Beans High phosorus � Nuts � Calciphylaxis � Hardened arteries � Weak bones � cola

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 14 th 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 Mc. Mann, 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 - Da. Vita. " Kidney Dialysis Basics - Da. Vita 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, 2 nd 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/MY 00281>. 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, 3 rd 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.