ERSD: End Stage Renal Disease

1. ERSD: End Stage Renal Disease Kathryn Atwater PVAMU Intern 2012-2013

2. Patient Background • 71 year old • Hispanic, white female • Middle Class • Separated • Lives with daughter • 3 children • History of tobacco use but no alcohol • Stage 5 Renal Failure

3. General Health History • Sleeps well • Light physical activity • Limited due to walker • Housework • Tries to “walk” as much as possible • Lost 50 lb over past year • Food intake varies based on daughter • Alert with some memory loss

4. Recent Medical History • First hospitalized 1/30/13 for: • Chronic CHF exacerbation • Anemia • 2/3/13 • CVC placed in right chest • High creatinine finalized decision (5.06 mg/dL) • Started hemodialysis immediately • No previous dialysis • Plans to get AVF as soon as possible

5. Past Medical History • Diabetes Mellitus • Hypertension • Congestive Heart Failure • Coronary Artery Disease • Hypercholesterolemia • Legally Blind • Glaucoma • Anemia • Heart Attack • Stroke

6. FamilyHistory • Mother: • Heart Attack • Diabetes • Kidney Cancer • Colon Cancer • Hypertension • No known medical history for father • Children in good health

7. Admission Values • Ht: 60” • Wt: 54.4 kg • Current Wt: 53.8 • IBW: 54 kg • %IBW: 99.6% • BMI: 23.11 • BP: 208/86 • Minor Edema • Stable Weight Trend • No swallowing or GI problems

8. LabValues

9. Medications Oral: • Acetaminophen • Nifedipine • Clonidine • Pravastatin • Docusate • Escitalopram • Lisinopril • Tramadol • Tums • IV • Epogen • Hectoral

10. Medication Descriptions

11. Medications Continued

12. General Diet History • Good appetite • Lost 50 lbs in past year • Small portions • Tries to “eat healthy, but depends on my daughter” • 3 meals a day • 1 snack • Says new renal diet is “tricky” but she’s trying

13. 24-hr Recall • Breakfast: 2 eggs over easy, 1 piece of white toast & 1 tsp butter • Lunch: Pepper chicken with snap peas, red peppers, and carrots, ½ cup white rice • Dinner: None (usually eats whatever daughter picks up after work) • Snack: 1 Mexican Cookie and a half of an apple

14. Dialysis Prescription • Type: Hemodialysis • Days: M-W-F • Treatment Length: 2.5 hr • BFR: 350 mL/min • Dialysate Flow Rate: 800 mL/min • Access: CVC catheter – Jugular (Right) • Average Fluid Gain: 1.6 kg • EDW: 52 kg

15. Patient Estimated Needs • Kcal: 1550-1600 • Protein: 60 g • Sodium: 2000 mg • Potassium: 2000 mg • Phosphorus: 800 mg • Fluid: 1000 mL

16. Diet Prescription • Renal Diet • Low Potassium • Low Phosphorus • High Protein • Carbohydrate Controlled • Low Fluid

17. Monitoring & Evaluation • Start taking Tums as a phosphate binder • Start Hectoral to decrease PTH levels • Increase Epogen to increase hemoglobin • Get fistula as soon as possible • Patient eager to participate actively • Prognosis: • GOOD!

18. ESRD: What is it? • End Stage Renal Disease • Stage 5 kidney disease • Kidneys • stop working i.e. kidney failure • <15% kidney function • PERMANENT • Need a transplant or dialysis to live • No cure • Goal of treatment: Slow progression

19. ESRD: Etiology & Pathophysiology • Progression of CKD • Main causes: • Diabetes • Hypertension • Kidney Failure=DEADLY • GFR <15 mL/min • Dialysis or Transplant required

20. ESRD: Diagnosis • GFR rate calculation • Urine Test • Blood Test • MRI • Biopsy

21. ESRD: Signs & Symptoms • General “ill” feeling • Itchy skin • Dry skin • Loss of appetite • Nausea • Edema • Muscle-twitching & cramps • Headaches • Decreased urine output • Poor concentration

22. ESRD: Treatment • Hemodialysis • Peritoneal Dialysis • Transplant • Not a cure • Last about 5-10 years • Strict guidelines

23. Treatment: Hemodialyis • Hemodialysis • Filter blood • Access Points • Clinic • Strict Diet

24. Treatment: Peritoneal Dialysis • Peritoneal Dialysis • Filter through peritoneum • Home • Through abdomen • Less Strict Diet

25. ESRD: Common Medicines • Binders • Hectoral • Sensipar • Epogen • Iron • Calcitriol

26. Renal Diet

27. Protein • Protein loss with dialysis • Affected by infection & trauma • Essential for: • Growth & development • Prevent infection • Healing • Tissue • Wound • HBV sources • Meat • Fish • Poultry • Protein Supplement

28. Potassium • Limit high potassium foods • Tomatoes • Potatoes • Bananas • oranges • High Potassium • Muscle weakness • Bradycardia • Cardiac arrest • Low Potassium • Vomiting • Diarrhea • Hypotension

29. Phosphorus • Poorly dialyzed • Phosphate binders • Renvela • PhosLo • Tums • High phosorus • Calciphylaxis • Hardened arteries • Weak bones • Avoid high phosphorus foods • Cheese • Dairy • Beans • Nuts • cola

30. Fluid • Fluid restriction • Approx 48 oz. per day • Based on: • Urine output • Interdialytic weight gains • Excess fluid: • Rapid weight gain • High blood pressure • Edema • Poor appetite

31. Physical Activity • Difficult for most • Benefits • Stimulate appetite & circulation • Improve cardiovascular risk factors • Hypertension • Hyperlipidemia • Diabetes • Obesity • Enhance sense of well-being

32. PES Statement • Limited kidney function related to end stage renal disease as evidenced by low serum calcium, anemia, low serum protein, high serum phosphorus, high PTH, and high serum creatinine levels.

33. Follow-up • Hemoglobin went up to 10.9, reduced Epogen dose • Fistula placed in left arm on March 14th • Understands disease & reason for treatment • Adjusting slowly but well • As of 3/15 moved out of daughters home • Patient says, “Will make it!”

34. Summary • ESRD is DEADLY if not treated properly. • Diet is the key component to keeping person in optimal health • Prognosis: • Good if sticks to plan • QUESTIONS?

35. References • McMann, L (ed): Pocket Guide to Nutrition Assessment of the Patient with Chronic Kidney Disease (3rded). New York, National Kidney Foundation, 2002. • "Kidney Dialysis Basics - DaVita." Kidney Dialysis Basics - DaVita. DaVita Inc., 2013. <http://www.davita.com/kidney-disease/dialysis/the-basics>. 17 Mar. 2013. • Bynam-Gray, L and Weisen, K (eds). A Clinical Guide to Nutrition Care in Kidney Disease. American Dietetic Association and National Kidney Foundation, 2004. • Drug Information Online: Drugs.com. 2013-2014. < http://www.drugs.com>. 19 March 2013 • K/DOQI: Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. Am J Kidney Dis 35(6), Suppl 2, 2000. • Kopple JD, Massry SG (eds): Nutritional Management of Renal Disease. Baltimore, Williams & Wilkins, 1997. • National Renal Diet, 2nd Ed. American Dietetic Association, 2002. • Pritchett, E. Medical Nutrition Therapy (MNT) for Chronic Kidney Disease. Real Nutrition Forum, the American Dietetic ASSN, Vol 22, No 1, Winter 2003. • Staff, Mayo Clinic. "Definition." Mayo Clinic. Mayo Foundation for Medical Education and Research, 11 Dec. 2010. <http://www.mayoclinic.com/health/hemodialysis/MY00281>. 18 Mar. 2013. • Stover, J (ed). A Clinical Guide to Nutrition Care in End-Stage Renal Disease. American Dietetic Association, 1994. • Wiggins, K. Nutrition Care of Renal Patients, 3rd Ed. The American Dietetic Association, 2001. • Zieve, David, MD, and Herbert Lin, MD. "End-stage Kidney Disease." U.S National Library of Medicine. U.S. National Library of Medicine, 21 Sept. 2011. <http://www.nlm.nih.gov/medlineplus/ency/article/000500.htm>. 16 Mar. 2013.