Clinical case study presented on Lupus and it\'s involvement with the kidneys and other organ systems.

1. LUPUS & THE KIDNEYS
Sarah Thelen
Dietetic Intern
Benedictine University

2. The Patient
oPatient data:
-65”
-167 lbs
-BMI: 28
oAfrican American female:
-lives with family
oAdmitted with c/o: fatigue, weakness, and
decreased intake
oAllergies: Sulfa

3. The Patient
oPatient with relevant medical hx:
-Systematic Lupus Erythematosus (SLE)
-Impaired renal function (Nephrotic
syndrome??)
-HTN
oClinical Impression:
-Active SLE
-Stomatitis
-Impaired renal function

4. Food/Nutrition
oPt experiencing stomatitis inferior to tongue, impinging
patient’s po intake
oPatient experiencing diarrhea, decreased intake, but still
very hungry
oPatient also did not have her dentures with her

5. Food/Nutrition
oPatient initially placed on clear liquids, and was advanced to
full liquids by the time I saw her initially
-Patient hesitant to advance because of her stomatitis
and related pain
-Ordered patient chilled Ensure- as she reported poor-
to-fair intake
oPatient reassessed three days later per protocol, and had
been advanced to a cardiac diet, where she reported good
intake
-Patient drinking all three cans of Ensure, and enjoying
it, and eating > 75% trays

6. Food/Nutrition
oMy recommendations at time of assessment:
-Ensure-chilled TID
-Advancement to soft renal diet, when patient’s intake
increases and can better handle solids
-Multivitamin PO
oRecommendations at time of reassessment:
-Addition of renal component to cardiac diet
-Continue with Ensure, BID
-Multivitamin PO

7. Nutrient Needs
oCaloric needs:
-Range: 20-25 g/kg
-1520-1900 calories
oProtein needs:
-Range: .8-1.2 g/kg
-60-91 g Protein
oFluids:
-30-40 mL/kg
-2280-3040 mL fluid

8. Lab Data
Labs 6/6 6/8
Albumin 2.3 2.3
Glucose 194 156
Na+ 142 143
K+ 3.4 2.8
Cl 110 109
CO2 20.6 26
BUN 31 39
Creatinine 2 3.2
C-Reactive Protein 98.46
24 Hour Urine Protein 7791 mg/24 hrs

9. Lab Value Discussion
oThis is a patient with renal insufficiency, and renal labs are
indicative of that.
oThis is a patient with SLE, her 24 hour protein urine, and
C-reactive protein can be indicative to support this
oK+  decreased levels indicate renal tubular
acidosis, where renal excretion of K+ is increased,
which is indicative of what the pt was experiencing
oCreatinine elevated creatinine levels indicate any
disease state effecting the kidneys, that is
compromising the kidneys and their ability to clear
creatinine
oCRP Acute phase, reactant protein used to
indicate inflammatory disease/inflammation, however
it is non-specific, and does not identify the source of

10. Lab Value Discussion
oChloride the elevated chloride can be indicative of renal
dysfunction as well as metabolic acidosis and renal tube
acidosis
oBUN Elevated BUN indicates renal disease, and can
indicate reduced renal blood flow, and increased protein
metabolism, which can explain the protein in the urine
oAlbumin Decreased albumin can also indicate nephritis, as
well as SLE

11. Medications
Medications Purpose Nutrition Implications
Pepcid Anti-GERD May decrease Fe, B-12 abs,
N/V/D, decrease gastric acid
secretions (not recommended
for those with decreased renal
function)
Heparin Anti-Coagulant Caution with: renal dysfunction,
hyperkalemia. GI bleeding, N/V,
abdominal pain
Solu-Cortef Anti-inflammatory N/V, dyspepsia, esophagitis
Sodium Antacid/Alkalizing Agent Increase in thirst, distension,
Bicarbonate caution with renal dysfunction,
cramps, flatulence
Vancomycin Antibiotic Bitter taste, nausea
Zosyn Antibiotic Dry mouth, taste changes,
N/V/D, flatulence, caution with
impaired renal funcion

12. Disease State
oPatient with active lupus, acidosis, and impaired renal
function, all of which are interrelated
oThe SLE causing an overall inflammatory state in the
body, primarily effecting the kidneys, and causing the acidosis.
oPatient is also with stomatitis, attributed to the lupus

13. Systematic Lupus
Erythematosus
oSLE is a chronic, autoimmune, inflammatory condition
oMarked by periods of remissions & exacerbations
oSLE is a “general” inflammatory disease but it does tend to
target organ systems of the body, and in many cases (~40%)
SLE will target the kidneys

14. Nephrotic Syndrome
Hypothesis
o40% of all people with SLE, and as many as two-thirds of
all children will develop kidney complications
oNephrotic syndrome can be caused by SLE, and her renal
labs, and proteinuria corroborate that even though it was
medically diagnosed or charted, there is a very good chance
this patient was experiencing Nephrotic symdrome
secondary to SLE
oThe acidosis, I also hypothesize originated with Renal
Tubular Acidosis, that occurred from the impaired renal
function due to the inflammation of the kidneys secondary
from the lupus

15. Nutrition Diagnosis
oWhen I originally assessed the patient her nutrition
diagnosis I gave her was:
“Inadequate oral food/beverage intake related to
stomatitis (secondary to SLE) as evidenced by pt
reporting good appetite but more intake because her
mouth hurts her”
oThis nutritional problem was resolved by the time I
followed up with the patient two days later, she was
eating well, and the stomatitis had cleared up for the
most part

16. Nutrition Intervention
oUpon speaking with the patient, I thought it best for her to
avoid the acidic/sugary juices on her tray
oChilled Ensure, and Protein shakes were ordered TID
oI suggested an MVI for the patient
oI suggested her diet be advanced as tolerated, and as the
stomatitis cleared up, to a renal soft diet, with an ideal
intake of > 75% of her trays

17. Nutrition Monitoring
oI followed up with the patient two days later, she had
been upgraded to a cardiac diet
oPt was not an MVI, which I suggested again
oI changed the chilled Ensure to BID
oPt was discharged the following day, June 9

18. Resources
oNutrition Care Manual, American Dietetic Association
o"Nephrotic Syndrome in Adults." National Kidney and Urologic Diseases
Information Clearinghouse. Web. 18 June 2011.
http://kidney.niddk.nih.gov/kudiseases/pubs/nephrotic/
oStaff, Mayo Clinic. "Nephrotic Syndrome: Tests and Diagnosis -
MayoClinic.com." Mayo Clinic. Web. 18 June 2011.
http://www.mayoclinic.com/health/nephrotic-syndrome/DS01047/DSECTION=tests-
and-diagnosis
o"Nephrotic Syndrome - PubMed Health." Pub Med Health. Web. 18 June 2011.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001520/
o"Nephrotic Syndrome: MedlinePlus Medical Encyclopedia." National Library of
Medicine - National Institutes of Health. Web. 18 June 2011.
http://www.nlm.nih.gov/medlineplus/ency/article/000490.htm

19. Resources
o"Renal Tubular Acidosis." National Kidney and Urologic Diseases Information
Clearinghouse. Web. 18 June 2011.
http://kidney.niddk.nih.gov/kudiseases/pubs/tubularacidosis/
o"LUPUS FOUNDATION OF AMERICA - Understanding Lupus." Lupus
Foundation of America. Web. 18 June 2011.
http://www.lupus.org/webmodules/webarticlesnet/templates/new_learnunderstandi
ng.aspx?articleid=2231