KAYLEE MCBRAYER DIETETIC INTERN APRIL 22 2015 NUTRITION

KAYLEE MCBRAYER, DIETETIC INTERN APRIL 22, 2015 NUTRITION IN HIV AND END STAGE AIDS

Overview Part 1 Part 2 �Disease State �Patient CJ �History �Nutrition Care Plan � 3 Ts �Outcome �Nutrition & HIV/AIDS �Conclusion �Barriers �Relevant Research

PART 1

WHAT IS HIV

CD 4 or “HELPER” T CELLS �Lymphocyte �Releases Cytokines �Works with CD 8 Cells & B Cells

WHAT IS AIDS? �Acquired Immunodeficiency Syndrome �Final Stage of HIV �CD 4 count is <200 cells/mm 3 AND/OR � 1 Opportunistic Infection (OI) �High Viral Load in Blood* It is false to think that everyone who has HIV will get AIDS

AIDS DEFINING OI’s �Candidiasis * �Cervical Cancer �Coccidioidomycosis �Cryptoccosis �Crytosporidiosis �CMV Retinitis �HIV Encephalopathy �Chronic Herpes Simplex �Histoplasmosis �Isosporiasis �Lymphoma �Kaposi’s Sarcoma * �Mycobacterium Avium Complex * �Tuberculosis �Pneumocystis Carinii Pneumonia (PCP) * �Recurrent Pneumonia * �Progressive Luekoencephalopathy �Salmonella Septicemia �Toxoplasmosis �HIV Wasting Syndrome *

AIDS DEFINING OIs

HISTORY 1884 -1924 1981/1982 1966/1970 1983/1984 1990 2012 1996 Today HIV is no longer a death sentence, dealing with new HIV health complications

STATS/ PROGNOSIS � 1, 201, 100 aged 13 and older living with HIV �# of ppl living increases but infection rate is stable �MSM most effected (in US), African American MSM, African Americans � 2013 - 47, 352 diagnosed �Prognosis is individual

3 Ts - TRANSMISSION TRUE � HIV can’t survive for long in air � Blood � Sex Secretions/Delicate Membranes � Breastmilk* � Spinal Cord Fluids � HIV has to get into bloodstream NOT TRUE � Daily Activities � Animals � Human Touch � Kissing � HAART Therapy = Safe

3 T’s TRANSMISSION 1. HIV is carried to CD 4 2. Binding & Fusion 3. Reverse Transcription 4. Integration 5. Transcription 6. Assembly 7. Budding 8. Cycle Repeats of e s u a t bec ncep o c s i Th T HAAR rtan o p m t is i

3 Ts -TREATMENT �HAART THERAPY �Pr. EP �o. PEP �n. PEP � 5 Different HIV drug classes �Generally take 3 ART drugs from 2 classes �Important for Drug Resistance �Genotype/ Phenotype Testing �Can be complicated �MANY interactions �MANY side-effects

3 Ts-THERAPY �Mental Health �Nutrition Therapy �Emotional Support

COMPLIANCE BARRIERS �Side Effects of Drugs �Scheduling �Size of Pill �AIDS Stigma �Fear of Seeking Healthcare �“Sentenced” to Meds �CAM �Religion/ Conspiracy Theories �Central Nervous System Issues �Support

NUTRITION IN HIV �Nutrition & Immunity �Preserve Lean Body Mass �Aid with Lipodystrophy �Prevent/Reverse Deficiencies �Food Security �Food Safety �Quality of Life �Support Medication Regimen �CAM �Comorbidities and Meds

LIPODYSTROPHY �Lipohypertrophy – More common with women �Lipoatrophy – More common with men

NUTRITION RELATED SIDE EFFECTS �Metabolic Changes �Insulin Resistance �Nausea �Vomiting �Diarrhea/ Malabsorption �Loss of Appetite �Bone Mineral Density �Swallowing Ability/Sores �Mitochondrial Toxicities �Hormone Changes

KEY NUTRIENTS �Multivitamins & Trace Elements �B-Vitamins �Vitamin C, E, A �Selenium �Zinc �Iron �Calcium/ Vitamin D/ Phosphorous

ADDITIONAL SUPPLEMENTS OF BENEFIT* �Probiotics �Whey Protein �Antioxidants �Alpha Lipoic Acid �N-Acetyl Cysteine

ACADEMY POSITION PAPER SUMMARY, 2010 � Prevent & reverse wt loss and � BMI, protein stores, wt loss of wasting � Maintain energy balance � ALWAYS support medication goals � Physical Activity � No evidence of supplementation effecting morbidity or mortality � MCT aids with fewer stools/absorbtion any kind, LBM � HIV increases REE � Higher Protein Diets seem to be beneficial � Fiber intake � Alterations of zinc, Fe, Se, Bvitamins, CHO, Fat may be shunted in HIV whether altered metabolism or inflammatory response or both

RESEARCH # 1

RESEARCH #1

RESEARCH # 2

RESEARCH #2

PART 2 NUTRITION CARE PROCESS IN END STAGE AIDS PATIENT CJ

HOSPITAL COURSE OVERVIEW �LOS – 10 Days �Initial Assessment (Screen & Consult) � 2 Follow Ups, Visited Often �Nutrition Education – Very Limited

Patient Overview � 22 y/o M �Ethnicity Unknown �Admit for SOB, Coughing w/ Sputum, Hypoxia, Tachycardia, Severe Respiratory Distress �Recent Hospitalization at University for PCP PNA �At ER, Disclosed not taking PCP or HAART Therapy �Unsure of last CD 4 count or Viral Load �Intial Dx: Respiratory Failure/Distress

Patient Overview, cont. �PCP PNA* – recurrent*, on steroids �Esophageal Thrush* �AIDS Cachexia, 15 lb wt loss in 2 mos. * �Swallowing Difficulties, not taking oral meds �Constipation

Medical History & Social Background �HIV+ (AIDS) �Bipolar disorder, depression, no drug or alcohol abuse, cachexia, insomnia �Unemployed �Lives w/ Brother, who is deaf

ANTHROPOMETRICS � 63 inches � 32 kg �BMI: 12. 5 �% IBW: 57 �IBW: 56 kg � 82% of Usual BW, UBW: 39 kg �% Wt Loss: Severe

LAB DATA LAB Value Glucose Normal LAB Value 129 CD 4 Count <20 L BUN 6 CD 4% 2 L Na 134 CD 4/CD 8 Ratio . 10 L HCO 3 21 CD 8% 74 H Albumin 2. 1 Lactate 5. 6 Mg 1. 7 WBC 2. 8 • Glucose, Lactate, Albumin, HCO 3 remained abnormal • NS @ 75 ml/hr – d/c when I saw him

MEDICATIONS �Azithromycin �Acylovir �Cefepime �Mirtazapine �Enoxaparin �Protonix �Fluconazole �Prednisone �Nystatin �Septra �Protonix �Ratepravir �Sulfamethox-TMP �Solu-medrol �Vancomycin

HOME MEDICATIONS �Acyclovir �Prednisone �Azithromycin �Zofran �Cyproheptadine �Zyprexa �Isentress �Raltegravir �Vitamin D 3 �Ergocalcifeol �Abilify �Depakote �Hydroxyzine Pamoate �Nexium

ENN • 1440 -1600 kcal (45 -50 kcal/kg of BW) • 64 -74 g pro (2 -2. 3 g/kg of BW) • 1 ml/kcal fluid

INTITAL ASSESSMENT �Per pt, appetite is fine but says swallowing is difficult for his PO meds, very lethargic �Follows a normal diet, occasionally drinks Boost that is provided – hates it. Prefers Ensure, Food Security, Received some nutr edu �Denies wt loss, says always thin �Regular Diet �PES: Increased Protein/Energy Needs Related to Metabolic Stressors/Current Condition AEB by BMI of 12. 5, 57% IBW, Severe Wt Loss

INTIAL ASSESSMENT, Cont Intervention 1. 2. 3. 4. Continue w/ current diet, will send Ensure TID along w/ HP Milkshakes TID/ HNS Snacks Recommend swallow study to assess dysphagia prescence – pt may benefit from nutrition support Request PAB Provide edu as appropriate Monitoring/Evaulation �Preserve LBM �Maintain Skin Integrity

First Follow Up �PAB of 21! �Suspected Pellagra �Mitochondrial Toxicity 2/2 to AZT �Metabolic Acidosis w/ Primary Respiratory Alkalosis �Placed on Thiamine & B-Vitamin Complex �Nepro 1 can BID ? (Renal Fxn normal) �Thrush is responding to treatment �Infectious Disease to re-evaluate for new HAART

First Follow Up, Cont �Eating fine, Nursing reporting eating fine, Very hungry �Reports he can’t swallow HAART, uncomfortable �Denies N/V/Diarrhea – BM �Some Stomach Pain �PES: REMAINS

First Follow Up, Cont. Intervention Monitoring/Evaluation Continue w/ current diet and supplements. Will honor food prefs 2. D/C Nepro 3. Revaluate medication regimen if feasible for swallowing �Preserve LBM 1. �Maintain skin integrity

NUTRITION EDUCATION �Fortification of Foods �Brief Food Safety �Touched on Importance of Meds and Following Instructions

SECOND FOLLOW UP �Nursing Staff to Check for Outside Drugs �Still not taking HAART, but taking all other PO meds �MD had spoke w/ pt regarding Meds* �Pt wishes for DNR status, contemplating hospice �PCP not responding to treatment �Left Pneumothroax discovered- chest tube �Lactic Acidosis resolved (d/c AZT) �Metabolic Acidosis continues, cause unclear �Add some chips �PES Remains

Second Follow Up, cont Intervention 1. Continue w/ current care plan, will honor food prefs Monitoring/Evaluation �Preserve LBM �Maintain skin integrity

OUTCOME �Home Care Hospice �Life expectancy, few days or weeks – per MD

PERSONAL IMPRESSION �HORRIBLE �Recommended Vitamin A or B-Vitamin Complex in Beginning �Better, more in-depth Nutrition Education �Outreach assistance, websites

REFERENCES