Renal Case Study

Ashlin Benesch Sharon Pokorny Lucy Ta Erin Manlulu Farin Farahzadi Zahra Orouji

Case Study Background

Mr. G: 45 YOBM Part 1: History of hypertension. Part 2: Kidney Failure and Hemodialysis Part 3: ESRD and Kidney Transplant

1.

Determine Mr. Gs IBW and percent of IBW IBW=166 pounds %IBW= 135.5%

106 + (6x10) = 166 pounds %IBW= (225/166) x 100= 135.5%

2. Determine his percent of UBW

%UBW= (225/205) x 100= 109.8.% %UBW=109.8%

3. Determine Mr. Gs adjusted body weight 166 + .25(205-166)=175.75 Adjusted BW=175.75 pounds (81.98kg)

4. Calculate his BMI weight: 225 pounds= 102.06kg height: 510= 177.8cm 102.06kg/(177.8)(177.8) = 32.2 BMI=32.2

5. Determine his protein needs. Recommended PRO intake: .8g protein per kg of body weight per day. (**using his adjusted body weight 175.75 lbs= 79.72 kg) 0.8g pro x 79.72 = 63.78g PRO/day

6. Using the Harris-Benedict equation, calculate his BEE

BEE=66.5 + (13.75 x kg) + (5.003 x ht) - (6.775 x age) ** Using adjusted body weight (175.75 lbs=79.72 kg)

66.5 + (13.75 x 79.72) + (5.003 x 177.8) - (6.775 x 45) 66.5 + (1096.15) + (889.53) - (304.875) = 1,747.31 BEE=1,747.31
7. Considering Mr. G as moderately active, calculate his total caloric needs for the day. BMR x AF= TEE

*Activity factor for a moderately active person is 1.55 1,747.3 x 1.55= 2,708.32 TEE= 2,708.32

8. Mr. Gs BP was 175/100. What does blood pressure mean? Is 175/100 something to be concerned about? Explain. Blood pressure is the measure of resistance of blood flow against the walls of the arterial vessels. Blood pressure is recorded as two numbers written as a ratio with the systolic blood pressure number on top and the diastolic blood pressure number on the bottom. -Systolic blood pressure: contraction of the heart muscle -Diastolic blood pressure: relaxation of the heart muscle The normal blood pressure is less than 120/80 mm Hg. Mr. Gs BP of 175/100 is a concern because this places his health condition in the stage 2 hypertension. It is a serious condition that requires lifestyle modification and drug therapy.

9. What are the functions of Capoten and Lasix? Capoten is a type of ACE inhibitor used to treat hypertension. It is also used to treat congested heart failure and diabetic neuropathy. Lasix (furosemide) is a diuretic to treat edema that causes you to make more urination, getting rid of the excess salt and fluid. It is also an antihypertensive drug that helps lower blood pressure. 10. List any nutritional complications of Capoten and Lasix. Capoten -Insure adequate fluid intake to avoid dehydration because this may cause a drop in blood pressure. -Avoid salt substitutes that contain potassium as it will interact with the drug and cause high levels of potassium in the blood. Lasix -Avoid natural licorice, which may counteract the diuretic effect of the drug. -Monitor diet high in potassium, magnesium, calcium because the drug may increase urinary excretion of these minerals as well as sodium.

11. List the principles of a 2 g Na diet.

Purpose: to control the sodium in the patients diet. Decrease the total amount of sodium to 2 g (2,000 mg) per day. Avoid these items as much as possible: - Salt (could consume up to 1/8 teaspoon, which is 300 mg of sodium, to season food) - Processed foods (canned foods, deli meat, cheese, instant cooking foods) - Sauces, condiments, seasonings (bouillon cubes, soy sauce, horseradish sauces, pickles, olives) Milk/Dairy (2 servings/day) -One serving has ~150 mg of Na Meat/Protein (Servings/day: 1 egg and two 3- oz servings of meat) -One serving has 60 mg of Na Vegetables and Fruits -One serving has only about 10 mg of Na Bread and Cereals (5 Servings/day) -One serving has ~ 150 mg of Na Desserts and Others -Limit or avoid commercial dessert mixes, cakes, pies, instant pudding

12. Identify any mistakes the RD may have made in this interview. Interrupted Mr. G when he was speaking Ignored Mr. Gs comments and questions about the plastic food by not answering him Overall lack of compassion and concern for Mr. G 13. Is there anything you would do differently? Explain. Be more understanding and respectful by listening to the patient and answering his questions. Be more patient by allowing Mr. G to finish his sentence. Gather additional dietary information by asking questions more thoroughly. i.e. What type of soda Mr. G consumes and does he add anything to his coffee? Have the wife come to a follow-up appointment with him since she prepares most of Mr. Gs meals

14. What are some good points about this interview? First made certain they both understood the reason for the nutrition consultation from the doctor. Used visuals to accurately estimate Mr. Gs portion sizes. Remained neutral and did not make judgments about Mr. Gs food choices Gathered important food information relating to nutritional factors associated with hypertension - i.e. Asked if his wife adds salt to his food and cooks with other seasonings.

15. What are the goals of nutritional therapy for Mr. G?

Dietary Approaches to Stop Hypertension (DASH) dietary pattern:

Rich in fruits, vegetables, low-fat dairy, and nuts Low in sodium, total fat, and saturated fat Adequate in calories for weight management

16. In one column, list the foods that Mr. G eats that are high in sodium. In a second column, list possible substitutes for the foods in column one.
High Na Foods Sausage Biscuit Meat Loaf Cheese Suggested Substitutes Beef, lamb, pork, poultry, and fish (fresh or frozen) Lean ground beef (fresh or frozen) Low-sodium cheeses, cream cheese, ricotta cheese, mozzarella Low sodium options, lemon juice with vinegar Season veggies with pepper or salt substitute Boiled potatoes, baked sweet potato fries Grilled chicken breast Unsalted peanuts/nuts, low-sodium peanut butter Unsalted popcorn, chips, and pretzels

Salad dressing Salt (with veggies) French Fries Luncheon Meat Salted Peanuts Crackers

Potato Chips

Fresh potatoes, unsalted chips, popcorn, and pretzel

17. In column one, list the foods Mr. G eats that are high in fat. In a second column, list possible substitutes for the foods in column one.
High Fats Foods Sausage Biscuit Meat loaf Suggested Substitutes Lean ground turkey, 95% fat free sausage Lean ground beef (Fresh or frozen)

Peanuts
French Fries Salad Dressing Potato chips Desserts (cake, pie, cookies) Mayonnaise Bacon fat in veggies Luncheon meat Cheese

Raisins, dried cranberries

Boiled potatoes, baked sweet potatoes Low fat options, lemon juice with vinegar Baked chips, banana/apple chips Low fat frozen yogurt Hummus, fat free sour cream, mustard Add small pieces of lean ham to veggies Lean ham, grilled chicken Fat free, low fat, or skim milk cheese

18. Based on the recall, approximate Mr. Gs energy and protein intake. Is he taking in too much, too little, or an appropriate amount? Based on Mr. Gs recall, he is consuming about 4,500 kcal/day His calorie intake per day is way too much compared with his BEE of 1,747 and even his TEE of 2,708 His protein intake, of 128 g/day, is also double what his daily needs of protein are.

19. Approximate Mr. Gs sodium intake (high, low, or appropriate).

Mr. Gs approximate sodium intake is 6,881 mg/day This is really high compared with the RDA of 2,400 mg/day.

20. Explain the relationship between BP and pedal edema. The distribution of fluids between any given body spaces are the result of pressure gradients, of which hydrostatic pressure (i.e. blood pressure) is one of the main components The more pressure inside the blood vessels, the more of a tendency there is to push fluid out of the vessels and into the tissues, thus edema In people with uncontrolled HTN, the heart has to work harder with every beat in order to circulate the blood against the increased pressure in the blood vessels and the harder it has to work, the bigger it gets. However, unlike other muscles, as the heart enlarges it weakens and becomes less able to pump blood effectively which causes a backup to form as the heart attempts to pump the same amount of blood with less and less efficient pumping. As this continues, fluid begins to collect in other parts of the body in response to gravity, which pulls the excess fluid to the lowest point of the body (lower legs and feet), which is called pedal edema. .

21. Should the RD be concerned about Mr. Gs calcium intake? Explain. The effect of increasing calcium intake with lowered blood pressure is unclear, although some research indicates minimal benefit Even though Mr. G is allergic to milk and does not like yogurt, the RD should not be concerned about Mr. Gs calcium intake because he is meeting his needs with his cheese consumption, combined with the calcium found in the sausage, meatloaf, and green beans that he consumes.

22. Considering Mr. Gs medication, diet, and recall, on a separate sheet of paper, outline the teaching program you would use for him. Include in your outline behavioral changes you would recommend, foods to avoid with appropriate substitutes, and foods to include. Explain why you are making changes.

Nutrition education programs on hypertension and renal disease Education on importance of taking medication and the consequences of not taking it Involve Mr. Gs wife into these programs as well Behavioral changes include weight reduction, increasing physical activity, reduced alcohol intake, reduce salt intake, stress management, or a combination of these. Mr. G should avoid foods that are high in fat and high in sodium. Substitutions for high fat and high sodium foods are mentioned above. Mr. Gs diet should include more fruits, vegetables, and whole grains. We are making these changes because if Mr. G continues with this kind of lifestyle, he may die of heart failure or kidney failure.

23. Explain why Mr. G had leg cramps and explain what he could do to prevent them.

Mr.G is taking Lasix, which is a diuretic. Many reported side effects of leg cramps. The study on this association is relatively weak. Taking diuretics can lower potassium levels in the body, which may have caused the leg cramps. He could prevent the leg cramps by doing the following: 1. Stretching out the calf and foot muscles before bed. 2. Use a heating pad or massage the foot and leg to help relax the muscles. 3. Loosening the covers and sleeping on your stomach with your feet hanging over the bed can help your legs relax. 4. Consulting the doctor about the leg cramps.

24. Explain the pathophysiology of renal disease and HTN. Blood pressure is the resistance in the blood vessels to the flow of blood. The diameter of the blood vessel affects blood flow. Regulators: a)Sympathetic nervous system (norepinephrine) b)Kidneys (renin) Some causes of hypertension are a hyperactive sympathetic nervous system, a stimulated renin-angiotensin system, and a low-potassium diet. Untreated or undertreated hypertension can lead to kidney disease.

Pathophysiology continued
There are many forms of renal disease: 1. Glomerular disease oNephritic syndrome - Hematuria oNephrotic syndrome - Protein losses in the urine 2. Acute renal failure is characterized by a oReduction in glomerular filtration rate (GFR) - Oliguria or normal urine flow 3. End stage renal disease (ESRD) oResult from having chronic diseases such as DM, glomerulonephritis, or hypertension oUremia 4. Kidney stones oComplex process that consists of saturation, supersaturation, crystal growth, and stone formation

25. Which lab values in Table 1 and which results of the urinalysis indicate that Mr. G has a renal problem?

Table 1 : oBlood Urea Nitrogen (BUN) oCreatinine oUric Acid

Urinalysis: oPositive Protein oPH of 8.1

26. Which lab values indicate protein malnutrition? In your answer, give the possible reasons for protein malnutrition and explain the relationship between protein in the urine and renal disease. Serum albumin indicates protein malnutrition. Mr. Gs serum albumin levels are lower than normal. Possible reason for protein malnutrition: protein is being excreted in the urine as shown in urinalysis lab results. Healthy kidneys will take wastes out of the blood, but leave protein. Impaired kidneys may fail to separate the blood protein, albumin, from waste products. Small amounts of albumin may leak into the urine (microalbuminuria). Microalbuminuria is a sign that kidney function is deteriorating. As kidney function worsens, the amount of albumin and other proteins in the urine increases (proteinuria).

27. Give the function and nutritional implications of Hectorol.

Used to treat secondary hyperparathyroidism in patients with chronic kidney disease (CKD) on dialysis or with Stage 3 or Stage 4 CKD. Hectorol Acts as active form of vitamin D for renal disease patients. Vitamin D helps with calcium absorption from the GI tract. Hectorol should not be given to patients who have hypercalcemia or evidence of vitamin D toxicity. Mineral oils and cholestyramine impair the intestinal absorption of Hectorol.

28. Explain the rationale for Mr. Gs meal plan. Include in your discussion the reasons for the following: 0.6 g of protein per kg of body weight Need to limit nitrogenous waste, which can delay or stop the progression of renal disease. 2 g sodium Must monitor because Mr. G has both hypertension and renal disease. -A failing kidney will filter and reabsorb less sodium and cannot adapt to changes in sodium intake. -This can lead to edema, hypertension, and congestive heart failure. No K restriction Some people in the early stages of CKD (pre-dialysis stages) do not need to limit their potassium intake. -No benefits in restricting potassium unless levels are high -Mr. Gs potassium levels were just slightly higher than normal. No fluid restriction Water requirement is not a major problem for patients with CKD who are not on dialysis.

29. Which lab values indicate Mr. G is anemic?

Red blood cell size and color: With iron deficiency anemia, red blood cells are smaller and lighter in color than normal. Hematocrit: This is the percentage blood volume made up by red blood cells. Hemoglobin: Lower than normal hemoglobin levels indicate anemia. The normal hemoglobin range is generally defined as 13.5 to 17.5 grams (g) of hemoglobin per deciliter (dL) of blood. Ferritin: This protein helps store iron in your body, and a low level of ferritin usually indicates a low level of stored iron.

Test Hgb Hct RBC

Result 11 g/dl 34% 4.5 x 106

Reference Units Conventional 14-17.4g/dl 42-52% 3.6-5 x 106/L

SI 140-174 g/L

3.6-5 x 1012/ L

30. Describe the AV fistula for hemodialysis. An arteriovenous fistula (AV fistula) is the connection of a vein and an artery through out the surgical process. The fistula develops over a period of months after the surgery. People with kidney disease can do exercises including holding a rubber ball to strengthen the fistula before use The surgical creation of an AV fistula provides a long-lasting site through which blood can be removed and returned during hemodialysis. A physician weeks or months before dialysis is started must prepare the fistula, which allows the person to be connected to a dialysis machine. When the vein and artery are joined, the vein gradually becomes larger and stronger, creating the fistula that provides vascular access years longer than other types of access and with fewer complications.

31. Describe hemodialysis and list the complications.

Hemodialysis is for those who still have some kidney function left. Hemodialysis: Hemodialysis is the type of dialysis that removes excess body wastes and fluids from blood as it passes through an artificial kidney. Basically, in hemodialysis, blood leaves the body, gets filtered by a machine called a dialyzer, and then returns to the body.

Hypotension: A decrease in blood pressure is the most frequent complication reported during hemodialysis. Cramps: In the majority of hemodialysis patients, cramps occur toward the end of the dialysis procedure after a significant volume of fluid has been removed by ultrafiltration. Febrile reactions: Febrile episodes should be aggressively evaluated with appropriate wound and blood cultures. Arrhythmia: On maintenance hemodialysis, patients are at risk of cardiac arrhythmias. Hemolysis: May result from a number of biochemical and toxic insults during the dialysis procedure. Hypoxemia: A fall in arterial PO2 is a frequent complication of hemodialysis that occurs in nearly 90% of patients.

32. List the dietary principles for a patient on hemodialysis. Limit Salt & Sodium: Lowering the sodium intake will help maintain good blood pressure control and limit the thirst. Limit the Potassium: Normal kidney function will remove potassium through urination. Kidneys that are not functioning properly cannot remove the potassium in the urine, so it builds up in the blood. This can be very dangerous to your heart. High potassium can cause irregular heartbeats and can even cause the heart to stop if the potassium levels get too high. Example: Bananas Orange Juice Tomatoes Cantaloupe NutsRed Beans Lima Beans Lentils Avocado Prunes Tomato Juice Tomato Puree Protein: People on dialysis need to eat more protein. Protein can help maintain blood protein levels and improve health. Eat a high protein food (meat, fish, poultry, pork, or eggs) at every meal, or about 8-10 ounces of high protein foods everyday

Grains/Cereals/Bread: Unless need to limit the calorie intake for weight loss and/or manage carbohydrate intake for blood sugar control, may eat, as desire from this food group. Grains, cereals, and breads are a good source of calories. Avoid whole grain and high fiber foods (like whole wheat bread, bran cereal and brown rice) to help you limit your intake of phosphorus.

Fruit/Juice: All fruits have some potassium, but certain fruits have more than others and should be limited or totally avoided. Limiting potassium protects your heart.

Vegetables/Salads All vegetables have some potassium, but certain vegetables have more than others and should be limited or totally avoided. Limiting potassium intake protects your heart.

Fluid Intake: People on dialysis often have decreased urine Output; so increased fluid in the body can put unnecessary pressure on the persons heart and lungs. Limit it by 4 cups a day. Fat: Dialysis patients should follow a diet low in saturated fat and cholesterol. These patients are considered the group at greatest risk for development of coronary artery disease. They often have increases in serum triglycerides and low highdensity lipoprotein (HDL) cholesterol.

33. Describe the function of Epogen and explain the kidney relationship with anemia. Epogen is the brand name for a synthetic version of erythropoietin. Erythropoietin is a hormone that normally is made in the body by the kidney, which is necessary to stimulate the bone marrow to produce red blood cells. Since the kidneys produce it, when kidney function drops below a certain point, anemia sets in. This usually does not represent a significant factor until late middle stage. Under normal conditions, when the body senses a decrease in red blood cells or a deficiency in the supply of oxygen, more erythropoietin is produced, and this increases the number of red blood cells. When this natural mechanism is not working, it may become necessary to stimulate the bone marrow to produce red blood cells. The erythropoietin that is used for therapy, Epogen, is man-made. Epogen belongs to a class of drugs called colony-stimulating factors because of their ability to stimulate cells in the bone marrow to multiply and form colonies of identical cells.

34. Convert 60 mEq K to mg (using information from your Chem classes)

60 mEq K = 60 millimoles =0.060 moles Atomic weight for potassium is 39.1 g

39.1 grams per mole (0.060moles) = 2.346 grams=2346 mg

35. Why did the protein in the diet order increase with ESRD? Maintenance of acceptable weight and serum proteins for prevention of renal osteodystrophy and reduction of cardiovascular risk.

Protein needs are higher in patients with ESRD due to losses that occur during dialysis. The recommended dietary protein intake for clinically stable maintenance hemodialysis patients is 1.2-g/kg body weight/day, and 1.2 -1.3g/kg-body weight/day for individuals on peritoneal dialysis . Some amino acids are removed during dialysis. A higher protein intake is needed to replace dialysis protein lost and to help keep you well nourished and healthy.
Protein can be increased to ensure that the decrease of muscle mass wont occur and that the body will have the resources to help fight infection. Especially important for malnourished and elderly patients

36. Explain the difference between the wet weight and the dry weight. Mr. Gs wet and dry weight: 215lbs (wet); 210lbs (dry) Most people on dialysis make little or no urine. The kidneys are not working properly, thus waste and extra fluid is built up in the body, accounting for the wet weight (before dialysis). Dry weight is the weight after dialysis treatment. This is the lowest weight reached without the patient developing low blood, which occurs if too much fluid is removed; or it is a weight that the patient is comfortable without feeling thirsty.

37. On the next page, create a NCP for Mr. G using all of the information since and including Tables 3 and 4. Use any pertinent information prior to Table 3 as his previous history. Patient is a 45-year-old male with history of uncontrolled hypertension (HTN), pedal edema, weight gain, resulting in end stage renal disease (ESRD). PES: Altered nutrition related laboratory values as related to change in ability to eliminate by-product of metabolism as evidence by elevated BUN, creatinine, and uric acid. 38. Calculate Mr. Gs BEE using the Harris-Benedict equation and the appropriate stress factor BEE = 1,747 x (1.2) stress factor = 2,096

39. Mr. Gs energy and protein requirements on hemodialysis are higher than his energy and protein requirements without hemodialysis. Explain why.

Hemodialysis drains body protein. Patients need to maintain a protein intake of 1.2g/Kg of body weight. Energy intake needs to be adequate as to spare the bodys protein for tissue protein synthesis and to prevent its metabolism for energy. Energy intake will depend on patients stress level, but within range should be between 25 and 40 kcal/kg of body weight.
40. The RD encouraged Mr. G to increase his caloric intake by eating more fat and sugar. Comment on the advantages vs. disadvantages of doing this with a patient who has renal disease.

Advantages: intake of fat and sugar ensure patient has adequate calorie intake needed during dialysis. Disadvantages: Higher cholesterol and fat intake, increase bad cholesterol and risk cardiovascular disease. High sugar intake will increase triglyceride levels in the body, which is a risk factor for cardiovascular disease.

41. The values indicating protein malnutrition are a little lower than they were the last time. Discuss what factors could be responsible for this. When Mr. Gs lab values were done the first time, he was at the beginning or middle stages of Chronic Kidney disease (CKD). His kidneys had mild to moderate decrease in kidney function, thus he was restricted on protein intake to allow for optimal protein usage, reducing the workload of the kidneys and excess waste in the blood, while slowing down the progression of kidney failure. The second time around his lab values revealed end stage renal disease (ESRD), at this point the kidneys have little or no function, and dialysis is needed. Mr. G was advised to consume a diet higher in proteins t a higher to maintain muscle mass and prevent loss of energy for protein tissue.

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