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  • 1. Medical Nutrition Therapy for a Chronic Kidney Failure Patient on Hemodialysis Michaela Meyer January 2005
  • 2. Medical Nutrition Therapy for a Chronic Kidney Failure Patient on Hemodialysis Introduction MH is was diagnosed with End Stage Renal Disease (ESRD) secondary to hypertension (HTN). Her secondary diagnosis include HTN, hypothyroidism, hypercholesterolemia, coronary artery disease (CAD), anemia (blood loss), atrial fistution, distolyic dysfunction, and congestive heart failure (CHF) secondary to volume overload. Social History MH currently resides at an assisted living facility where she eats most of her meals. Her son grocery shops for her. MH is physically inactive except for walking to the dining room every day. She wears glasses and has some hearing loss. MH is a nonsmoker and nondrinker. She is planning to undergo a root canal in January. Significant Medical History MH was hospitalized in 2002 to undergo cataract surgery for glaucoma and cataracts. She was hospitalized again in 2003 for coronary angioplasty and pacemaker due to bradyarrhythmia. MH was diagnosed with renal failure in 2003. She was hospitalized at this time for left upperarm fistula and catheter placement. In 2003, MH started hemodialysis. MH’s list of current medications are listed in the table below.
  • 3. Medication List for MH Medication Amount Use Nutritional implications Synthroid 1 PO QAM hypothyroidism take on empty stomach Amiodarone 200mg 1 QD antiarrhythmic agent no grapefruit juice Docusate 100mg 1 PO TID stool softener take with fluids Coumadin as directed, anticoagulant control Vit. K intake Celebrex 200mg 1 BID NSAID (arthritis) take with food Nephrocap 1 QD renal vitamin take with food Nexium 40mg 1 30 min before breakfast GERD/esophagitis Altace 10mg 1 PO QHS ACE inhibitor no grapefruit juice Zocor 40mg 1 QHS antilipemic agent no grapefruit juice Diltiazem calcium channel CD 240mg 1 QAM blocker Emla Cream as directed local anesthetic Renagel 800mL 2 with meals phosphorus binder take with meals Dulcolax 1 PO QHS PRN laxative do not take with milk Zofran 4mg 1 tab Q8o PRN antiemetic monitor potassium Restril 30mg 1 QHS PRN Aranesp 5mcg IV Q Monday anemia tx avoid ethanol Zemplar 3 mL with tx hyperparathyroidism tx Nutritional History MH has had a history of low albumin. The table below indicates her albumin levels for the past year. Over the past 11 months, MH has also had a weight loss of 3.5kg or 5%. Her most recent weight change was an increase of 0.5kg in December. MH has had some problems with high phosphorus in the past year, as shown in the table. Currently, her phosphorus is being controlled through diet and phosphorus binders. Her potassium level has been WNL each month for the past year. MH is taking a renal vitamin to make up for the water soluble vitamins that are lost during dialysis. She has a history of anemia, which is currently being treated with Aranesp.
  • 4. 2004 Labs K+ URR Kt/V Alb Hgb Ca PO4 Prod PTH Iron Dry Wt. Ave gain Wt. % January 4.9 0.84 2.15 3.5 11.8 10.3 5.3 55 72.5 2.0 2.8 February 4.0 0.84 2.11 3.7 10.9 10.6 3.9 41 50 71.5 2.0 2.7 March 4.4 0.84 2.14 3.8 12.9 10.8 5.3 57 173 71.5 2.0 2.8 April 4.4 0.82 1.98 3.5 13.5 10.4 3.9 41 45 71.5 2.1 2.9 May 4.6 0.79 1.79 3.6 13.6 10.0 5.2 52 381 71.5 2.2 3.1 June 4.5 0.82 2.04 3.7 11.4 10.3 5.9 61 271 52 70.0 2.3 3.3 July 4.4 0.83 2.13 3.7 12.9 11.0 4.3 47 176 70.0 2.2 3.2 August 4.7 0.79 1.82 4.0 13.8 10.3 6.1 63 357 43 69.5 2.3 3.4 September 4.6 0.80 1.90 3.8 14.0 12.0 4.0 48 57 69.0 2.2 3.1 October 4.7 0.79 1.82 3.7 13.8 10.7 5.2 56 54 68.5 2.1 3.0 November 4.4 0.82 2.01 3.5 13.1 10.4 5.4 56 68.5 2.4 3.5 December 4.5 0.84 2.19 3.5 12.2 10.5 4.6 48 343 42 69.0 2.1 3.1 Adj Ca (Dec) 10.9 MH’s diet order is 100mEq potassium and 1500mL fluid. In November 2004, MH stated that she eats 3 meals a day with a light noon meal on non-dialysis days and 2 meals a day on dialysis days. She states that she knows she is not eating as much protein as she should. She usually eats 6 eggs a week and 2-3oz meat with her evening meal. She has been encouraged to use protein powder in the past, but currently only uses it 1-2 times a week because she gets tired of eating applesauce. MH has been experiencing some constipation due to the dialysis treatments and fluid restrictions and some gas. She has no known food allergies or intolerances. In January 2005 MH stated that she is now using protein powder 3 times a week in her oatmeal. She has started bringing the protein powder to the dining room with her. MH has also added shaved deli turkey as a snack, and she is consuming 8 eggs a week.
  • 5. Chronic Kidney Failure (CKF) MH’s high BUN and Creatinine are clear indicators that she has chronic kidney failure (8). MH’s renal failure was caused by her history of hypertension. A large number of problems can result from the kidney’s inability to excrete nitrogenous wastes. Therefore, the CKF patient must be treated through dialysis or a kidney transplant to prevent uremia. Fluid and Electrolyte Balance Renal failure can result in fluid and electrolyte imbalance because the kidneys are responsible for regulating water and solute balance. Fluids and electrolytes are monitored through edema, between treatment fluid gains, blood pressure, dietary intake, and serum Na levels (4). A fluid gain of 2-3 kg or 2-5% of body weight is expected to occur between dialysis treatments (4). Restricting dietary intake of fluids and sodium can help control edema and high fluid gains. Fluids should be restricted to 1L a day and sodium should be restricted to 2g a day in patients who are anuric (9). Potassium and Vitamins Potassium is responsible for controlling muscle contractions, including the heart muscle. Consequently, hyperkalemia or hypokalemia in CKD patients can rapidly lead to death from arrhymthia (2). This is a concern for MH, who has a history of bradyarrhythmia. Abnormal potassium lab values can be controlled through the choice of dialysate and by restricting or increasing the dietary intake of high potassium foods. Salt substitutes, which have a large amount of potassium, should be avoided in patients with hyperkalemia (5).
  • 6. Loss of water soluble vitamins occurs during dialysis, thus a supplement is recommended for dialysis patients (10). Multivitamins should be chosen carefully so they do not contain Vitamin A or high doses of Vitamin C. Renal vitamins are suggested over multivitamins to prevent vitamin deficiency (10). Protein Status Protein-calorie malnutrition can occur in CKD patients who do not consume adequate protein or calories to spare protein use as energy (6). Malnutrition in CKD patients increases risk of death and hospitalization (10). Malnutrition is assessed through weight, BMI, anthropometrics, skinfold measurements, and albumin. Serum albumin is the most significant predictor of risk of mortality and morbidity. Risk of death and hospitalization increases as serum albumin decreases (10). Anemia Management Anemia is a common result of CKF since the kidneys are responsible for secreting erythropoietin, which acts on stem cells in bone marrow to stimulate RBC production. A deficiency of erythropoietin in CKD causes anemia (5). Currently Aranesp is being used to treat MH’s anemia. Aranesp stimulates red blood cell production to correct anemia. MH’s anemia is under control as determined by her normal Hct, Hgb, MCV, MCHC, and MCH lab values (5). Anemia, as indicated by low serum ferritin and low TSAT, may require IV iron or EPO (5). In studies, ferritin and transferrin saturation increased significantly and iron deficiency decreased after supplementation (2).
  • 7. Renal Bone Disease MH is currently being monitored for renal bone disease. In patients with CKD, the kidneys are unable to maintain calcium-phosphorus homeostasis, thus potentially resulting in osteoporosis, osteodystrophy, or osteitis fibrosis. This is evident in the calcium, phosphorus, and Parathyroid Hormone (PTH) lab values (4). Hyperphosphatemia, elevated CaXP product, excess calcium intake, and elevated PTH are all risk factors for calcification of the cardiac tissues, which can lead to death (8). MH has had problems with elevated PTH, calcium, and phosphorus in the past thus putting her at risk for renal bone disease. Her December lab values indicate high PTH (343) and adjusted calcium (10.9); therefore, in December, MH was started on Zemplar to control renal bone disease. PTH labs were ordered again in January, and the value was still high at 512. Cardiovascular Risks Cardiovascular disease is the leading cause of death in patients with CKD (8). Chronic kidney disease is an independent risk factor for cardiovascular events (1). The risk is progressive. Each 10-unit reduction in GFR below 81 mL/min/1.73m2 is associated with a 10% increase in the relative risk of death or nonfatal cardiovascular complication (1). Renal dysfunction is a powerful independent predictor of fatal and nonfatal adverse cardiovascular outcomes (1). MH has an increased risk for cardiovascular disease due to established CAD. She does not have a cholesterol profile available to assess; however, she will be at greater risk if her LDL cholesterol > 160 mg/dL and triglycerides > 500 mg/dL (5). The usual pattern of hyperlipidemia in hemodialysis patients is mild to moderate hypertriglyceridemia, low to mildly elevated
  • 8. cholesterol/LDL, and low HDL (5). Hyperlipidemia in CKD patients is caused by increased hepatic production of cholesterol and impaired removal of circulating LDL and VLDL (5). All CKD patients should be screened for hyperlipidemia. If hyperlipidemia is an issue, weight control, reduced carbohydrate intake, and exercise can all improve high cholesterol. However, the renal diet takes priority over hyperlipidemia (5). Blood Pressure MH has had a history of high blood pressure, which eventually resulted in her impaired renal function. The kidneys regulate blood pressure through the rennin- angiotensin mechanism. When blood volume is low, rennin is secreted from the glomerulus. This rennin forms angiotensin. Angiotensin causes vasoconstriction and stimulates aldosterone secretion causing sodium to be reabsorbed and blood pressure to return to normal (4). High blood pressure is a major risk factor for CVD in patients with CKD (8). Hypertension is treated by dietary sodium reduction and fluid control (5,8). Weight control, physical activity, and moderation in alcohol can also benefit CKD patients with HTN (8). Dialysis MH’s treatment for CKD is dialysis. She is not a good candidate for transplant, which is the only cure for kidney failure. During dialysis, blood passes through the semipermeable membrane of the artificial kidney. Waste products are then removed by diffusion and fluids are removed by ultrafiltration (4). MH has been on dialysis since 2003. Access was obtained through a fistula in her left upper arm. Her current dialysate is 2K 2.5Ca. Her dialysis is effective as determined by her KT/V value, which measures
  • 9. the removal of urea from the patient’s blood over a given period of time. The URR is the reduction in urea before and after dialysis, and this also indicates that MH’s dialysis is effective (5). Role of Medical Nutrition Therapy Diet plays a large role in the health status of CKD patients on dialysis. The goals of MNT for CKD patients include: to maintain good nutritional status through adequate protein, energy, vitamin, and mineral intake; control edema and electrolyte imbalance by controlling Na, K, and fluid intake; prevent or slow growth of renal osteodystrophy by controlling Ca, Ph, and Vit. D; enable the patient to consume a palatable diet that fits his/ her lifestyle (4). These goals can be achieved by counseling the patient on making appropriate food choices, taking medications as prescribed, maintaining adequate protein intake, maintaining lab values within acceptable limits, and maintaining an exercise program (7). Regular dietary counseling based on the individual’s needs is essential for dialysis patients, especially those with low albumin values. Subjects that received dietary counseling had a higher rate of increase in serum albumin levels than subjects who took an oral supplement (3). Assessment MH’s lab values and the desired ranges are indicated below (6,8). MH is at high nutritional risk because of her low albumin labs. Dialysis drains body protein, so more protein is needed in her diet to improve albumin levels (4). MH improved her efforts to increase p.o. intake of protein and protein powder since receiving dietary counseling in
  • 10. November. In November, MH’s pertinent nutritional labs were mostly WNL, with the exception of albumin. Her phosphorus was getting a little high at 5.4, but was still WNL. High phosphorus levels can pose many problems. Hyperphosphatemia can result in osteodystrophy, decrease in the effectiveness of calcitriol, increase PTH production, and contribute to metastatic calcifications (5). MH’s high phosphorus labs have been associated with high PTH labs, as expected. Hyperparathyroid bone disease may cause phosphorus to be released from the bones, which may be a contributor to MH’s high phosphorus labs (5). Previously the phosphorus binder, PhosLo was being used, which increased MH’s calcium levels. In December, her phosphorus binder was changed to Renagel to control calcium levels. Calcium must continue to be monitored closely as her adjusted calcium is high. MH is 62”/157.48cm tall. Her dry weight is 69kg. Overall energy intake may need to be increased if a downward trend in weight continues (5). The average fluid gains from the last 3 tx in January was 2.4kg. Her desired body weight according to HANES II is 64kg. Her BMI is 27. Weight was not adjusted. Anthropometric labs taken in August of 2004 indicate that her AMA is 75-90%ile, which is a 4.6% decrease from the previous year. Her AFA is in the 90-95%ile, which is a 14% decrease from the previous year. Although her arm mass is decreasing, she is not at risk for malnutrition since she is still in a high percentile (9). The right arm was used for measurements, and a medium frame was used.
  • 11. Lab values from Lab values from 11/10/04 12/6/04 BUN 67 51 Post-Tx BUN 12 8 Creatinine 8.2 7.9 P 5.4 4.6 K 4.4 4.5 Cl 94 L 94 L CO2 26 28 Ca 10.4 Adj. Ca 10.8 H 10.5 Adj. Ca 10.9 H Albumin 3.5 L 3.5 L Total Protein 7.2 6.6 AST 17 LDH 213 219 Alk phos 62 72 RBC 3.87 L WBC 7.6 RDW 13.9 Hgb 13.1 12.2 Hct 39.6 TLC 1890 PLT 186 MCV 102 H MCH 33.8 H MPV 8.8
  • 12. MCHC 33.1 ferritin 294 Iron 42 UIBC 121 TIBC 163 TSAT 25.8 PTH 512 Determining Caloric Needs – (6,8) Calories: 69 kg X 30 kcal/kg = 2,070 total kcals/day Protein: 69 kg X 1.3 g/kg = 89.7 g protein/day = 359 kcal Fat: 2,070 kcals X 30% = 621 kcal = 69 g fat CHO: 2,070 – 359 – 621 = 1,090 kcal = 273 g CHO Na: 2-3 g/day K: 69 kg X 40 mg/kg = 2,760 mg/day P: 800-1,000 mg/day Fluid: 1,000 mL/day Recommended Nutrition Therapies and Rationale MH was encouraged to increase her intake of protein. Estimated protein needs were set higher for MH than for most hemodialysis patients because MH’s albumin has been so low. A low albumin has been associated with higher mortality rates in dialysis patients, so it is essential to return the albumin level to 4.0 or greater. For MH, a lower albumin goal may be more realistic given her history of low albumin levels. Protein intake will be increased through the increased use of protein powder. MH was encouraged to use protein powder at breakfast or the noon meal, since MH is typically not consuming meat then. Since MH is discouraged from using protein powder because she is tired of eating applesauce, ideas of other foods that protein powder could be mixed with (including hot cereal) were brainstormed. In addition, MH was encouraged to add a snack once a day that includes meat such as lunch meat roll-ups or lunch meat with low-sodium crackers to increase protein intake. The snack will also help improve
  • 13. MH’s caloric intake to help maintain her weight. Other foods that are high in protein and appropriate for the patient’s diet order include: eggs, egg substitutes, fish, chicken, beef, pork, and other meats. The phosphorus binder she was taking, PhosLo, consisted of calcium acetate, which negatively impacted her calcium levels. In November, her adjusted calcium was 10.8. Renagel was considered as an alternative phosphorus binder in November. In December, MH’s adjusted calcium was 10.9, and a switch was made to Renagel for her phosphorus binder. MH was praised by the dietitian for her good lab values to encourage her to keep up the good work with the potassium and fluid restrictions. A positive environment was created to help prevent MH from becoming discouraged at all of the dietary requirements. MH was also encouraged to continue to comply with all new medications. Continued monitoring of MH’s labs, especially albumin, is essential to gauge how well she is doing with her nutritional goals. Continue to monitor PTH to evaluate the effectiveness of the new medication, Zemplar. Monitor weight for any changes, which will indicate nutrition status. If a downward trend in weight continues, increase total energy intake to prevent further weight loss. A lipid profile is recommended for MH to properly assess her risk for cardiovascular problems. Exercise could benefit MH in many ways and was encouraged for the patient. Exercise could prevent further loss of muscle mass. It can also lower blood pressure and improve lipid levels, if they prove to be a problem. Make a referral to the exercise specialist to encourage MH to exercise while she is at dialysis. Summary
  • 14. MH seems to be a very motivated individual who is willing to work to meet her nutritional goals. She has some barriers that get in the way of healthy eating habits (ex: tired of applesauce, lacking ideas for protein sources), but once they were addressed by the dietitian, her optimism and compliance improved. Her expected prognosis is fair, depending largely on her albumin trends. Should they continue to decline, her risk of morbidity and mortality will be greatly increased.
  • 15. Resources (1) Anavekar, N, et al. Relation between Renal Dysfunction and Cardiovascular Outcomes after Myocardial Infarction. The New England Journal of Medicine, 2004; 351 (13): 1285-95. (2) Kopple, J. and Massry, S. Nutritional Management of Renal Disease. Baltimore: Williams & Wilkens, 997. (3) Akpele, L. and Bailey, J. Nutrition Counseling Impacts Serum Albumin Levels. Journal of Renal Nutrition, 2004; 14(3): 143-148. (4) Mahan, LK, and Escott-Stump, S. Krause’s Food, Nutrition, and Diet Therapy. Eleventh edition. Philadelphia: Elsevier, 2004. (5) National Kidney Foundation. Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease. Third Edition. 2002. (6) Beto, J. and Bansal, V. Medical Nutrition Therapy in Chronic Kidney Failure: Integrating Clinical Practice Guidelines. Journal of the American Dietetic Association, 2004; 104: 404-409. (7) American Dietetic Association. Guidelines for Nutrition Care of Renal Patients. Third edition. 2002. (8) American Dietetic Association. Renal Care: Resources and Practical Application. 2004. (9) Daugirdas, J., Blake, P., and Ing, T. Handbook of Dialysis. Third edition. Philadelphia: Lippencott Williams & Wilkins, 2001. (10) Ahmad, S. Manual of Clinical Dialysis. London: Science Press, 1999.

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