Newly Diagnosed Hemodialysis Spenser Parker January 15, 2014

Overview O Patient History and Admission O Background of the Disease O First Research Article O Application to Patient O Nutrition Care Process O Second Research Article O Summary O Personal Impression

Patient Profile O KR is a 56 year old female O Hispanic O Family in Texas O On disability due to injury O Admit on September 18, 2013 O Discharged on September 27, 2013

Health History O Chief compliant of bilateral flank pain O History of: O Hypertension-not medicated O Cervical Cancer O Hydronephrosis O Nephrolithiasis O Surgical History of: O Stent placements in 2012 O Radium implants

Physiology O Function of the kidneys O Filter 20-25% of the blood per minute O Waste products/unused electrolytes O What the kidneys are made of O Glomerular filtration rate(GFR-ml/min) O Collecting Tubules-Ureters McCance & Huether 2002, p.1172

Renal Failure O Acute Kidney Injury (AKI) O GFR is suddenly reduce O Toxic Drug Exposure O Allergic Drug Reaction O Ischemic Acute Tubular Necrosis O Nephrolithiasis O Kidney Stones O Most common are calcium stone formation Mahan & Escott-Stump, 2008 p.929

Renal Failure O Hydronephrosis O Accumulation of urine in the collecting tubules O Usually caused by some kind of obstruction O Damages GFR O Chronic Kidney Disease O Five Stages O Diabetes, Hypertension, Glomerulonephritis O Happens over a period of time Mahan & Escott-Stump, 2008 p

ESRD O Symptoms include: O Nausea and Vomiting O Decrease in urine production O Muscle weakness O Metallic Taste in Mouth O Treatment options: O Transplantation O Hemodialysis or Peritoneal Dialysis Mahan & Escott-Stump, 2008 p

Nutrition for Renal Failure O Usually no nutrition intervention for AKI O For ESRD three electrolytes need to watch O Sodium O Potassium O Phosphorus O Fluid Restriction Mahan & Escott-Stump, 2008 p

An Educational Project for Patients On Hemodialysis to Promote Self-Management Behaviors of End Stage Renal Disease O Objective: provide an overview of the benefits of educating patients with ESRD on HD about their disease, diet, treatment, and medication to promote self-management behaviors O 26 participants O First took a pre-test to assess patients knowledge Lingerfelt & Thronton, 2011 p

An Educational Project for Patients On Hemodialysis to Promote Self-Management Behaviors of End Stage Renal Disease O Educational Intervention-ESRD handbook and one-on-one 30 minute sessions to review and answer questions for 4 weeks O Afterwards patients then took the same pre test again O Results: pre-test ranged from 3 to 21 and post-test 15 to 23 Lingerfelt & Thronton, 2011 p

Application to Patient O Initial Diagnosis of hydroureteronephrosis O Obstruction was believed to be from radium implants from treatment of cervical cancer O Urologist consulted for nephrostomy tubes O Dialysis catheter was considered O Although kidney function was thought not to improve

Medications O Acetaminophen O Calcium gluconate O Ceftriaxone O Epoetin O Famotidine O Heparin O Renal MVI

Nutrition Care Process O Interview O Assessment O PES Statement O Relevant labs O Education O Follow Up Visit

Interview O KR was undergoing dialysis at time of interview O Didn’t eat much 3-4 days PTA O Didn’t have much appetite (50%) since admit O Nausea and vomiting were improving O Was on renal diet O Had poor dentition

Anthropometrics O KR is 5 foot 6 inches O Weighs kg or 235 pounds O Ideal Body Weight of 58.97kg O KR is 181% of IBW O Adjusted body weight of 71kg O BMI of 38.3

Macronutrient Needs O 30-35kcal/kg using ABW kcal O g/kg using ABW gm O Fluids need up to MD (anuric) O Correction O 25-30kcal/kg using ABW kcal

Relevant Labs Cr 9.55H10.10H9.83H9.34H8.24H7.12H7.02H4.99H BUN 60H64H68H 63H51H50H30H GFR 4L 5L6L 9L Alb. 3.2L2.3L2.6L2.5L2.8L 3.2L K L3.9 Phos. 5.5H4.8H3.64.0

PES Statement O Increased nutrient needs related to current condition of ESRD secondary to starting hemodialysis as evidenced by intake record and low albumin.

Education O Standard Renal Education O Low potassium O Low phosphorus O Low sodium O Family Support O Throwing Out food

Follow Up Visit O Propass Mousse BID O Gave chopped meats O On KR’s follow up visit O No Nausea/vomiting O Increased appetite O Follow up questions O biscuits

Prediction of malnutrition using modified subjective global assessment-dialysis malnutrition score in patients on hemodialysis O 66 patients were included in the study that was conducted in India O Anthropometrics measurements were taken after dialysis (height, body weight, tricep skin fold) O Biochemical markers used: Albumin, Total Protein, Cholesterol, Transferrin, Ferritin, Total Iron Binding Capacity, BUN, Creatinine Janardhan et al., 2011 p.38-45

Prediction of malnutrition using modified subjective global assessment-dialysis malnutrition score in patients on hemodialysis O SGA-Dialysis Malnutrition Score: O Weight change, dietary intake, GI symptoms, functional capacity, co-morbidities, muscle wasting, subcutaneous fat O Mean SGA score was ( in women and in men) O Body weight showed a negative correlation with SGA (p=0.037) O TSF showed a negative correlation with SGA (p=0.054) O Albumin(p=0.049) Total Iron Binding Capacity (p=0.026) Ferritin (p=0.042) Transferrin (p=0.046) Janardhan et al., 2011 p.38-45

Summary O Many ways someone can end with renal failure O KR resulted in having ESRD through hypertension and long period with an obstruction O The key to success on dialysis is proper education and family support O It is a lifestyle change, but can be managed

Personal Impression O Interesting how KR resulted with ESRD O Education was well received O Obese non diabetic O Attitude that KR had after once placed on dialysis O Changes for calories (experience)

References O Beto, J. (2010). Improving First-Year Mortality in Patients On Dialysis: A Focus on Nutrition and Exercise. Nephrology Nursing Journal, 37, 61-65, 98. O Dixon, J., Borden, P., Kaneko, T. M., Schoolwerth, A. C. (2011). Multidisciplinary CKD Care Enhances Outcomes At Dialysis Initiation. Nephrology Nursing Journal, 38, O Janardhan, V., Soundararajan, P., Rani, N., Kannan, G., Thennarasu, P., Chacko, R., Maheswara, R. C. (2011). Prediction of malnutrition using modified subjective global assessment-dialysis malnutrition score in patients on hemodialysis. Indian Journal of Pharmacuetical Sciences, 73, O Lingerfelt, K. L., & Thronton, K. (2011). An Educational Project for Patients On Hemodialysis to Promote Self-Management Behaviors of End Stage Renal Disease. Nephrology Nursing Journal, 38, O Mahan, L. K., & Escott-Stump, S. (2008). Krause’s food & nutrition therapy, 12 th ed. St. Louis, Missouri: Mosby, Inc. O Mazairac, A. H., Grooteman, M. P., Blankestijn, P. J., Lars Penne, E., Van Der Weerd, N. C.,... Bots, M. L. (2012). Differences in quality of life of hemodialysis patients between dialysis centers. Quality of Life Research, 21, doi: /s O McCance, K. L, & Huether, S. E. (2002). Pathophysiology: The biologic basis for disease in adults & children, 4 th ed. St. Louis, Missouri: Mosby, Inc.