Renal Mini Case Study

By Melissa Jakubowski

Patient InformationInitials: M.H.Female72 years oldFull codeNKFA1st date of chronic HD Tx: 8/10/20101st date of Tx at Fresenius: 8/20/2010

Socioeconomic/Family StatusRetiredLives at home with husbandHusband prepares mealsDenies alcohol/illicit drug useH/o of smoking, quit 35 years ago

Anthropometric DataHeight: 62”Weights:

EDW: 54.50kg (119.9 lbs.)

Pre-weight: 55.80kg (122.8 lbs.)

Post-weight: 54.30kg (119.5 lbs.)

• No recent weight gain/loss

BMI: 22.0 (LBW)IBW: 131-158 lbs.91.5% IBWIDWG: 1.3kg

Interdialytic Weight GainIDWG

Recommendations: <3kg on weekdays<4kg on weekendsOr

<5% of EDW Equals 2.7kg for

this patient

• IDWG: 1.3kg

Biochemical DataLab Value Current ValueHemoglobin 10.9Hematocrit 34.9 ↓Potassium 4.6BUN 65Creatinine 5.8Calcium 9.4Corrected Calcium 9.8 ↑Phosphorus 4.4Albumin 3.5 ↓Parathyroid Hormone (PTH)

189.1

Abnormal Lab ValuesLab Value Current

ValueNutritional Significance

Hematocrit 34.9 ↓ CKD → decreased EPO

Corrected Calcium

9.8 ↑ Low albumin

Albumin 3.5 ↓ ???

Serum Albumin History

Dec Jan Feb Mar Apr May3.2

3.3

3.4

3.5

3.6

3.7

3.8

3.9

4

Albu

min

(g/

dl)

Admitting DiagnosisDiagnosis PathophysiologyESRD (on HD)

secondary HTNHypertensive

nephropathy & nephrosclerosis

Lupus (SLE)Kidney mass

Past Medical HistoryPMH Pathophysiology

CAD HTN, h/o smoking, older age, dietary habits

MI CAD

PTCA Surgical treatment of CAD

HTN High sodium diet, h/o smoking, CKD

Lupus Unknown; possibly hereditary

2cm Right Kidney Mass H/o smoking, HTN

Contrast neuropathy Renal insufficiency, specifically ↑ creatinine

HD AccessLeft

AV Graft

Cath

Placements

Right AV fistula

Infection

Temporary

Currently

MedicationsMedication IndicationAspirin (acetylsalicylic acid)

Prevention of blood clotsPain (neuropathy) & inflammation (Lupus)

Lopressor (metoprolol) HTN

Prednisone (corticosteroid)

Lupus

Zocor (simvastatin) Hyperlipidemia

Renagel (sevelamer HCl) ESRD re: serum P levels

Fish oil (omega-3 fatty acids)

Hyperlipidemia

Nexium (esomeprazole) ↓s risk for gastric/duodenal ulcers

Prednisone Side Effects↑ N urinary excretionInduces negative nitrogen balancePathophysiology of low albumin

Abnormal Lab ValuesLab Value Current

ValueNutritional Significance

Hematocrit 34.9 ↓ CKD → decreased EPO

Corrected Calcium

9.8 ↑ Low albumin

Albumin 3.5 ↓

Prednisone

Zocor Patient EducationAvoid/limit

grapefruit and other citrus fruits which inhibit the liver enzymes responsible for metabolizing Zocor

SupplementsDialyvite: Renal MVI,

primarily containing B-complex vitamins, folic acid, essential minerals

Vitamin C: limited to 60-100mg/day to avoid formation of calcium oxalate kidney stones

Protein supplement 3x/week (Nepro or Zone Bar)

Nutrition NeedsCalorie Protein30-35kcal/kg:

1600-1900Harris-Benedict:

1500Mifflin-St. Jeor:

1000

1.2-1.3g/kg: 65-71g

FluidsFluid restriction of 1500mL (standard

restriction for HD patients that produce < 1 L of urine/day)

1500mL = 50 fl. oz.

Current Dietary Recommendations↑ protein diet (65-71 g/day)P restriction (800-1200 mg/day)K restriction (2000 mg/day)Na restriction (1500-2000 mg/day)Fluid restriction (1500 mL/day)

PES StatementIncreased protein, calorie, and vitamin &

mineral needs related to ESRD on HD as evidenced by LBW (BMI = 22) and low serum albumin (3.5g/dl)

InterventionsNutrition Rx: continue as recommendedProtein supplement: continue as orderedDialyvite & P-binder: continue as prescribedEncourage intake of high biological value

(HBV) protein foods (eggs, meat, poultry, fish)

Continued HD diet education

GoalsTo be achieved by next follow-up (48 hours):Lab (alb): to trend toward standardEDW: stable IDWG per standards Pt. to report:

Dietary adherence to nutrition rx100% supplement intakeOral intake amount per her normal; good

appetiteMVI and P-binder taken daily as prescribed

Monitoring/EvaluationLabs, especially K, P, Ca, Alb, PTHPt. self-report: oral supplementation intake,

oral intake/appetite, and GI SxLevel of the knowledge: continued

verbalization of nutrition rxWeights (EDW, pre-weight, post-weight) to

determine IDWG and assess adherence to fluid restriction and dialysis sufficiency

Change in medical history, especially regarding the kidney mass

Questions???