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Case Study Presentation-Rachael Joseph
- 1. + MNT CaseStudy: Accelerated (Acute) Renal Failure, Secondary to Renal Transplant Rejection Rachael G. Joseph Oakwood University Dietetic Intern 2015-2016 5/5/2016
- 2. + Objectives To understand: The pathophysiology of acute renal failure The causes of transplant rejection The appropriate nutrition interventions for renal transplant patients
- 3. + Organ System &Function The urinary system is comprised of the kidneys, ureters, bladder, and the urethra. The function of the kidneys it to filter wastes and fluids from the bloodstream, and also: keep levels of electrolytes, such as potassium and phosphate, stable help regulate blood pressure (renin) make red blood cells (erythropoietin) keep bones strong urine from the kidneys and store it until releasing it from the body.
- 4. + Disease Pathophysiology & Progression Whatis renal failure? Renal failure refers to temporary or permanent damage to the kidneys that results in loss of normal kidney function. Acute Renal Failure Causes/Etiology: Usually occurs in people with diabetes, existing kidney disease, liver disease conditions that cause decreased blood flow to the kidneys, direct damage to the kidneys, or blocked ureters
- 5. + Disease Pathophysiology & ProgressionCont’d Symptoms: Decreased urine output (although occasionally urine output remains normal) Edema Shortness of breath Fatigue Confusion Nausea Seizures or coma in severe cases Chest pain or pressure
- 6. + Treatments: Treating the underlyingcauses of AKF If caused by a lack of fluids in blood, IV fluids may be recommended by MD In other cases, AKF may cause edema. Diuretics may be recommended to remove excess fluid Temporary hemodialysis to remove the toxins and excess fluids.
- 7. + Alport Syndrome &Chronic Kidney Disease Alport syndrome is a genetic condition characterized by kidney disease, hearing loss, and eye abnormalities. It affects approximately 1 in 50,000 newborns. Almost all affected individuals have hematuria. Many people with Alport syndrome also develop proteinuria. As this condition progresses, the kidneys become less able to function thus resulting in end-stage renal disease (ESRD). Significant hearing loss, eye abnormalities, and progressive kidney disease are more common in males with Alport syndrome than in affected females.
- 8. + Alport Syndrome &Chronic Kidney Disease Cont’d Mutations in genes result in abnormalities of the type IV collagen in glomeruli, which prevents the kidneys from properly filtering the blood and allows blood and protein to pass into the urine. Gradual scarring of the kidneys occurs, eventually leading to kidney failure in many people with Alport syndrome. Type IV collagen is also an important component of inner ear structures, such as the area that transforms sound waves into nerve impulses for the brain. Mutations that disrupt type IV collagen can result in misshapen lenses and an abnormally colored retina.
- 9. + Alport Syndrome &Chronic Kidney Disease Cont’d
- 10. + Nutrition Therapy forKidney Transplant Patients Diet is less restricting than when on HD Medications will affect the way the body works Cyclosporine- Vitamin E (reduces the required amount of drug needed, Grapefruit and pomegranate increase level of drug in blood) Prednisolone make it harder for the body to use extra carbohydrates which lead to high BG levels Limiting salt after surgery is usually standard, especially in use with steroids that cause water retention. Water retention can cause, high BP and sodium can amplify the problem. Protein needs increase immediately after surgery, but can return to normal after healing Potassium intake can return to normal so long as the transplant is working well
- 11. + Kidney Transplant Procedure Deceased (cadaveric)- Organ comes from someone that has just died Living Related Donor Living Unrelated Donor
- 12. + Transplant Surgery Thesurgery is performed under general anesthesia and usually takes 2-4 hours A kidney transplant is considered a heterotrophic The surgeon will make a small incision on the lower abdomen, just above the groin The new kidney is placed in the front part of the lower abdomen, in the pelvis The surgeon connects the pre-existing artery that carries blood to the kidney, and the pre-existing vein that carries blood away from the kidney The ureter is then connected to the bladder
- 13. + Causes of TransplantRejection Up to 30% of people will experience a form of kidney transplant rejection. Most rejections happen within six months after transplantation, but it can still happen years down the road. In most cases, if treated quickly the rejection can be reversed. Caused by: clots, fluid collection, infection, side effect of medication, problems with the donor kidney, Non- compliance, recurrent disease, acute/chronic rejection.
- 14. + Medications Used toSuppress Kidney Rejection Immunosuppressive agents are used to protect the kidney from being recognized as a foreign object in the body Prednisone (glucocorticoid): Anti-inflammatory drug administered via IV or orally. Immunosuppressive drug used to prevent organ rejection. Anti-proliferative drugs: Azathioprine, Mycophenolate mofetil, Mycophenolate sodium, Sirolimus Cytokine Inhibitors: Cyclosporine, Tacrolimus. Lowers T- cell activity Antilymphocyte Medications
- 15. + Patient Profile AdmitDate: 2/15/2016 31 y/o, Caucasian male with a past medical history for Alport syndrome Admit Dx: Accelerated Renal Failure with Renal Transplant Rejection. Also w/inflammation and edema. Presented to the ER for elevated creatinine Past Hx of ESRD, secondary to Alport syndrome Dialyzed from 2008-2009 Past surgeries include: Peritoneal catheter placement, Perm-A- Cath placement and removal, and Kidney Transplant
- 16. + Patient Profile Cont’d Current Rx regimen: Amplodipine- High BP Ferrous Sufate- Anemia Lansoprazole- decreases stomach acid Losartan- vasodilating effects Mycophenolic acid- immunosuppressant Prednisone- immunosuppressant Sodium bicarbonate- slow the rate of progression of CKD/acid-base balance Tacrolimus- immunosuppressant
- 17. + Medical History Pt.missed his office visit with nephrologist in fall of 2015 Patient telephone MD in mid December from San Francisco stating he had swollen legs and elevated BP Patient came to ER on 1/8/2016 with elevated creatinine, potassium, and lowered bicarbonate Pt. already showed signs of antibody mediated rejection Received a pulse dose of steroids and immunosuppression was continued. Required dialysis for a short period in January 2016 Pt. was able to recover his renal function and was discharged home
- 18. + Medical Data Admit Weight:83.2 kg Current Weight: 83.2 kg Height: 182.9 cm BMI: 24.9 Nutrition Related Labs Upon Admission (2/15/2016): BUN -65/Creatinine -3.8 Phosphorous N/A CO2 -12
- 19. + Nutrition Assessment (ADIME) Initialassessment, Screening: Performed on 2/18/2016 Appetite: Good-75% Food Preference: Likes food, but hydralazine causes decreased appetite, describes hazy feeling Nutrition Medication Review: amlodipine, ferrous sulfate, furosemide, heparin, hydralazine, metoprolol, protonix, tacrolimus, prednisone Dx- accelerated renal transplant rejection, acute-on-chronic renal failure Hx- kidney transplant
- 20. + Assessment Cont’d Current DietOrder: Renal Diet PO intake: 75% (per RN) Current Nutrition Risk Level: Moderate Nutrition Status: Appetite Good Skin Intact, Braden 22, No wounds to review Nutrition Related Labs BUN - 56/Creatinine - 3.0 Phosphorous - 4.6 CO2 - 18
- 21. + Assessment Cont’d &Nutrition Diagnosis Estimated Nutrition Needs Protein: 58-75 g/day (0.7-0.9 g/kg) Energy: 1830-2163 kcal/day (22-26 kcal/kg) Fluid: 1664-2084 mL/day (20-25 mL/kg) Pt. PO intake meets 78/96% of estimated low-end kcal/protein needs. Fluid per MD due to renal transplant rejection. Nutrition Diagnosis #1 P: Impaired nutrient utilization NC-2.1 E: Related to altered nutrient metabolism S: As evidenced by abnormal BUN/Creatinine
- 22. + Intervention & Monitoring/Evaluation Nutrition Goals #1 Meet 75% of estimated needs/all sources #2 Tolerate oral diet by discharge #3 Be weighed within 7 days #4 Maintain skin integrity during hospitalization Nutrition Plan/Recommendations: Check lab results Monitoring: Oral intake, Calorie and protein needs, Labs results and Weight *Pt. expressed a prior knowledge of Renal Diet education
- 23. + Summary of Treatment& Progress RD followed up once. Pt. was experiencing transplant rejection resulting from non- compliance with medications MD noted no acute indication for dialysis at the time, but informed Pt. if no evidence of recovery he may need PD vs. HD
- 24. + Follow Up Assessment:2/19/2016 Pt. seen at bedside. He is very knowledgeable about the renal diet and how to control his blood glucose. He mostly tries to follow a ketogenic diet, appetite varies based on meds, specifically hydralazine. Continued with renal diet with 100% PO intake recorded. Labs: K+ 3.4, Cl 113, BUN 55, Creatinine 3, Albumin 2.4 Meds: furosemide, mycophenolic acid, protonix, prednisone, tacrolimus Skin: Braden 21, Nutr 3 GI: I/O +4334 mL, Last BM on 2/17 Admit Wt: 84.1 kg, Current Wt: 83.2 kg Wt. change likely due to fluids Estimated needs: 1700-2100 kcal/day 59-76 gm pro/day Currently meeting needs
- 25. + Follow Up Assessment:2/19/2016 Cont’d Nutri Dx: Altered nutrient utilization, related to altered nutrition related labs, altered protein metabolism as evidenced by abnormal BUN/Creatinine Recommendation: 1. Continue Renal Diet 2. Monitor weight, labs, PO intake, I&O Goals: 1. Nutrition meets more than 75% of needs 2. Maintain and preserve lean body mass
- 26. + Outcomes and PostDischarge Analysis The nephrologist saw the patient while in the hospital. Creatinine level has improved significantly(3.8 to 2.9), however BP remained high. The MD adjusted the Pt.’s medication, and is no longer on prednisone, Lansoprazole, and losartan. The Pt. is staying on the same medications upon admission with furosemide, hydralazine, metoprolol added. Pt. was discharged and was to follow up with nephrologist within 3-5 days. * It is not known if the patient met with the nephrologist after * discharge, if they recovered enough renal function to avoid HD or PD, or if they were compliant with their medications
- 27. + Role of theRD Nutrition Education to prolong kidney function Introduce and explain functions of kidney friendly foods to Pt.’s diets Advising Pt.’s on the nutritional needs at the different stages of CKD, ESRD, as well as life after the transplant takes place
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