CKD stage 3 case study

CASE STUDY 3Lindsay Johnson

Michelle Ten

Tara Sarvghad TousiAthena Bechere

Kirandeep Samra

Photo: Google Drive

Meet John Doe, 86 y/o MaleDx: HTN, COPD, unspecified psychosis, CKD Stage 3, Dementia

Photo Google drive, 6-3-2016

HTN Pathophysiology, Etiology1

74 million Americans have HTN and 26 million CKD

Two main causes HTN & CKD in U.S. are:

● Primary HTN (unknown cause); Diabetes

● Secondary HTN (underlying disease); High blood pressure

● Age, ethnicity, gene expression (both diseases)

Kidneys control BP:

● Renin

● Activates RAS

Labs indicative HTN organ disease:

● Cr >1.5 mg/dL (2.1 mg/dL)

● Proteinuria 1+ (urine albumin)

● Albumin <3.5 g/dL (3.3 g/dL)Photo kidneysmart.org, 6-3-2016

CKD Stage 3 Pathophysiology & Comorbidity2,3

● Decreased GFR = excretion waste products, fluid & electrolyte balance, synth. hormones (macrocytic anemia)

● Symptoms = malaise, weakness, N/V, muscle cramps/itching, metallic taste, neurologic impairment (psychosis)

http://www.thevisualmd.com/center/?idg=8313&t=9314

Photo Kidneysmart.org, 6-3-2016

COPD Pathophysiology, Comorbidity4,3

Systemic inflammation r/t CVD, CKD?● Prevalence COPD was related to kidney function

● COPD was present in 47% patients eGFR <60

● Strongest in Pts with moderate CKD

● long-term mortality in patients with CKD

http://www.thevisualmd.com/read_videoguide/?idu=1083618873&q=COPD%20video

Photo Encyclopedia Rocks, 6-3-2016

Nutrition Assessment➔ Age - 86 years old➔ Sex - Male➔ Height - 67” (5’7”/170cm/1m70cm)➔ Weight - 145# (65.9kg) → [There is a weight loss from 148.8# to 145#]➔ IBW - 148# ➔ %IBW - 98%➔ BMI - 22.7kg/m2 (within normal levels)

➔ Medical Hx: Dementia, unsp Psychosis, HTN, COPD, CKD stage 3➔ Usual intake: feeds himself and appetite is good, consumes 100% of his breakfast,

100% of his lunch, and 75% of his dinner.➔ Diet order: Renal, recommended Suplena TID (8 oz, 3x/day)

Photo Specialneeds, 6-30-2016

Nutrition Assessment

→ EER + 125% = 4440 - 5180 kcals/day → Est Pro needs (0.8 - 1.2 g/CBW) = 53-79 g/kg

→ Est Fluid needs = 1648 cc/day (25 mL/day)(Six 8 oz. c H20/day, unless urine output normal, customized by Pt reported urine vol., handout given “How to Limit Fluid Intake”)

→ Laboratory Values: FPG: 78 mg/dL (N), creatinine: 2.1 mg/dL (H), albumin: 3.3 g/dL (L), BUN: 42 mg/dL (H), total PRO: 5.3 g/dL (L) RBC: 4.32 uL (L), MCV: 97.7 fL (H) eGFR: 30 mL/min

Photo Medifitbiologicals, 6-3-2016

Nutrition Diagnosis5

1. Inadequate protein-energy intake related to current disease state, as

evidence by wt loss from 148.8# in April to current wt of 145#, pt is 98%

IBW, low serum albumin 3.3 g/dL, and low total protein 5.3 g/dL.

2. Altered nutrition-related laboratory values related to CKD stage 3 as

evidenced by ↑MCV, ↓RBC, and ↓eGFR.

Photo Bradleydibble, 6-20-2016

Nutrition Intervention6

Nutrition Prescription:

● ↑ 1977- 2307 kcal/day● ↑ PRO 1.2 g/kg (HBV)● ↑ Folate, B12 (Suplena 8oz TID)● Rx Renal MV, folate and B12, 25(OH)D, EPO (Macrocytic Anemia)

Photo NKDEP, 7-1-2016

Nutrition Intervention6

Nutrition Education (Content):

Nutrition relationship to disease: ● Educate Pt importance ↑ protein and total energy in diet (CKD/COPD)● Teach Pt 50% HBV protein ● Utilize Health Belief Model prevent ↓eGFR, Pt lifestyle/diet changes ● Educate Pt on potential food-drug interaction through handout

Recommend modifications: ● Customize meal plan using exchanges, portion sizes to meet kcal and PRO goals● Sodium and fluid intake customized according to Pt urine output, symptoms, lab values● 3 day food journals

Photo NKDEP, 7-1-2016

Nutrition Education Handout 7

Nutrition Intervention6

Nutrition Education (Application):

Short term goals: ● For 2 weeks, Pt ↑ protein sources low in P (beans, fish and poultry). ● Pt eliminates salt when cooking (~2g Na/day goal)● Pt drinks six 8oz c water/day● ↑ folate and B12 by ingesting Suplena 8oz TID

Long term goals: ● Pt will demonstrate understanding of portion sizes, HBV PRO, ↑B12/folate through supp, ↓

sodium/fluid. ● Pt will be referred to exercise physiologist/Senior classes preserve LBM.

Photo NKDEP,7-1-2016

Monitoring & Evaluation

Monitor lab values to determine if Pt complies with nutrition Rx 1 week prior to appointment

➔ Albumin➔ BUN➔ Creatinine with eGFR➔ Chloride➔ MCV➔ Potassium➔ RBC➔ PRO, total➔ Sodium

Photo MNT 2Yourhealth, 6-30-201616

Monitoring & Evaluation

➔ Follow up with RD within 2 weeks

➔ Monitor weight, LBM, BMI

➔ Evaluate fluid status◆ Pt urine output◆ Presence of edema

Photo Healthylifestyleart, 6-30-2016

Photo Wardoundstuff, 6-3-2016

Photo Loveyourkidneys, 6-3-2016

Monitoring & Evaluation

➔ Evaluate Pt food intake, 3-day food journals◆ Monitor Pt appetite, modify diet as needed

➔ Assess Pt functional status via anthropometric measurements bi-weekly◆ Follow-up on recommended exercise

● 30 min/day, 5 x/week

➔ Refer followup mental status examination

Photo ddce.utexas.edu,, 6-30-2016

Photo Freshfoodperspectives, 6-30-2016

Photo Entwellbeing.au., 6-30-2016

References

1. Escott-Stump, Sylvia, and Janice L. Raymond. "Medical Nutrition Therapy for CVD." Krause's Food and the Nutrition Care Process. By Kathleen L. Mahan. 13th ed. Saint Louis: Elsevier Sanders, 2012. 758-61. Print.

2. Escott-Stump, Sylvia, and Janice L. Raymond. "Medical Nutrition Therapy for Renal Disorders." Krause's Food and the Nutrition Care Process. By Kathleen L. Mahan. 13th ed. Saint Louis: Elsevier Sanders, 2012. 814. Print.

3. "Chronic Kidney Disease Health Center." Chronic Kidney Disease Health Center. Ed. The Anatomical Travelogue LLC. The Visual MD, 2014. Web. 01 July 2016.

4. Y. R. B. M. Van Gestel, M. Chonchol, S. E. Hoeks, G. M. J. M. Welten, H. Stam, F. W. Mertens, R. T. Van Domburg, and D. Poldermans. "Association between Chronic Obstructive Pulmonary Disease and Chronic Kidney Disease in Vascular Surgery Patients." Nephrology Dialysis Transplantation 24.9 (2009): 2763-767. Web. 30 June 2016.

5. Association, American Dietetic. "Reference Manual." International Dietetics & Nutritional Terminology. American Dietetic Association, 2011. Web. 2 July 2016. <http:///www.nutritioncaremanual.org>.

6. National Kidney Disease Education Program (NKDEP, Nkdep. "CKD and Diet | Assessment, Management, and Treatment." CKD and Diet: Assessment Management and Treatment (n.d.): n. pag. National Kidney Disease Education Program (NKDEP. NIH, Apr. 2015. Web.

7. "Drug Interactions Checker Drugs, Food & Alcohol." Drugs.com. Ed. Micromedex® Kluwer™. Cerner Multum™, 30 May 2016. Web. 01 July 2016.

Q&A?

Thank You!