Renal Mini Case Study By Melissa Jakubowski
Renal Mini Case Study
By Melissa Jakubowski
Patient Information
Initials: M.H.Female72 years oldFull codeNKFA1st date of chronic HD Tx: 8/10/20101st date of Tx at Fresenius: 8/20/2010
Socioeconomic/Family Status
RetiredLives 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 Gain
IDWG Recommendations: <3kg on weekdays<4kg on weekendsOr
<5% of EDW Equals 2.7kg for
this patient
• IDWG: 1.3kg
Biochemical DataLab Value Current Value
Hemoglobin 10.9
Hematocrit 34.9 ↓
Potassium 4.6
BUN 65
Creatinine 5.8
Calcium 9.4
Corrected Calcium 9.8 ↑
Phosphorus 4.4
Albumin 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
Alb
um
in (
g/d
l)
Admitting Diagnosis
Diagnosis Pathophysiology
ESRD (on HD) secondary HTN
Hypertensive 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 Access
Left
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 Education
Avoid/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 Needs
Calorie Protein30-35kcal/kg:
1600-1900Harris-Benedict:
1500Mifflin-St. Jeor:
1000
1.2-1.3g/kg: 65-71g
Fluids
Fluid 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)
Interventions
Nutrition 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???