1. Bennington Wentworth Keene State College Dietetic Intern
CKD-Stage 5 with SBO
Bennington Wentworth
Keene State College Dietetic Intern

2. UConn Health Located in Farmington, CT 224 Beds
Teaching Hospital (John Dempsey)
Also includes UConn School of Medicine, Dental Medicine, and Graduate School
Smaller branches in Storrs and Canton, but are outpatient
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3. Role of RD at UConn Health
Clinical/Outpatient Dietitian
Provides Medical Nutrition Therapy
Provides Nutrition Education
Assess nutritional needs based on Standards of Care
Write diet orders for oral diets and parenteral nutrition
Makes recommendations for total parenteral nutrition

4. CKD Stage 5 Complete or close to complete failure of the kidneys
eGFR less than 15
Need for dialysis or transplant
MNT
Protein grams per kg
Unless on dialysis then g/kg
Elevated kcal needs (30-35 kcal/kg)
Monitor/restrict sodium, potassium, phosphorus, and fluids

5. Risk Factors of CKD Diabetes HTN Glomerulonephritis
Causes inflammation and damages the filtering units in the kidneys
Polycystic Kidney Disease
Obstructions such as kidney stones, tumors, or enlarged prostate in men

6. Complication Associated w/CKD
Protein-energy malnutrition
Uremic state and increased protein catabolism
Altered metabolism
Ca, Phosphorus, and Vitamin D
Electrolyte and fluid imbalances
HTN, edema, CHF, severe hyperkalemia
Dyslipidemia and abnormal carbohydrate metabolism
Increases risks for CVD
Anemia
Low Iron Stores

7. Small Bowel Obstruction (SBO)
Blockage in the small intestines usually caused by scar tissue (surgery), hernia, Crohn’s Disease, or cancer
Accounts for 300,000 hospitalizations with a total of 800,000 days of inpatient care, which is equivalent to $1.3 Billion in healthcare costs.
Meds: motility agents and stool softeners/ laxatives

8. SBO Complications Fats and fat soluble vitamin malabsorption
Vitamin B-12 malabsorption
Electrolyte imbalances
Na/K+

9. MNT for SBO Bowel rest, so NPO status and if prolonged consider TPN
When PO is appropriate, advancement from CL to FL to small frequent low residue meals (individualized)
Kcals: kcal/kg IBW
Protein or g/kg IBW
Fluids: 30 ml/kg or Per MD

10. V.V.
57 y.o. Male
Admitted 6/19 (multiple admissions) 61 kg cm, BMI 21
Medical Hx:
Type 1 Diabetic
Stage 4 CKD
Hypertension
Vitamin D Deficiency
Anemia
Edema
Admitted to ED w/bilateral lower leg pain and swelling x1 month
Diet Hx:
Followed diabetic diet at home, had previous education in the past (diagnosed at 35 y.o.)
Social Hx:
3 Sisters and Mother involved in care
Lives with two roommates
Works as paralegal
Family Hx:
Coronary Artery Disease is Father
Multiple family members with Type 1 Diabetes
Estimated Needs: 1672 kcal, 48.8 g (0.8 g/kg), and 1525 ml (25 ml/kg)
Pt with egg allergy

11. Medications Norvasc Lipitor Rocaltrol ANCEF Fentanyl Haldol Humulin
Xylocain
Lopressor
Protonix
Neo-synephrine
Senokot-S
Glucagon
Dilaudid
Narcan
Zofran

12. Nutrition Diagnosis
Severe protein calorie malnutrition related to high grade SBO as evidenced by 4.7% weight loss over 6 days and meeting less than 50% of estimated needs over 5 days
Diet Order: NPO
Intervention: Continuous 65 ml/hr Day 1 Dex 11.9% Day %, AA 4.7%
Monitoring/Evaluation: Wt, labs (electrolytes, blood glucose, BUN/Cr), BM

13. First Admission
6/19-6/27

14. Clinical Course Day 1 6/19 Day 2 6/20
Arrived at ED w/ complaints of bilateral lower leg pain and swelling x1 month
Labs drawn: BUN 63 (H), Cr 4.4 (H), eGFR 13.9 (L)
Plan for admission
Day 2 6/20
Admitted
Meds: Norvasc and Lasix
Diabetes managed on insulin pump
Labs: A1C 6.2, BUN 61 (H) Cr 4.4 (H), eGFR 13.9 (L)
Dx: Microcytic normochromic anemia
Discussing possibility of dialysis

15. Clinical Course Day 3 6/21 Day 4 6/22 Believed to have DM Nephropathy
Plan for OP meeting with nephrology
Started on Iron supplement
Day 4 6/22
Seen by Clinical Nutrition
PES Statement: Altered nutrition related lab values related to Stage 4 CKD as evidenced by Potassium level of 5.3 and Phosphorus level of 5.0
Labs: Phosphorus 5.0 mEq/L (H), Potassium 5.3 mEq/L (H)
Provide Nepro BID

16. Nepro Nutrition supplement used for patients on dialysis
Provides 425 kcal per can with g Pro
Formula is low in Potassium (250mg), Phosphorus (170mg), and Sodium (250mg)

17. Clinical Course Day 5 6/23 Day 6 6/24 Seen by Clinical Nutrition
Altered nutrition related lab values related to Stage 4 CKD as evidenced by elevated potassium and phosphorus levels.
Labs showed elevated Phosphorus at 6.9 mEq/L (H) and Potassium at 5.5 mEq/L (H)
Ordered for Low Phosphorus (1 G), Low Potassium (1.5 G) Diet
Day 6 6/24
Diet changed to Renal (2G Na, 1.5G K, 1G Phos)
Potassium lowered to 5.3 mEq/L (H), Phosphorus remained the same at 6.9 mEq/L (H)
Decision made to have in-patient renal biopsy on 6/25

18. Clinical Course Day 7 6/25 Day 8 6/26 Pt NPO due to planned procedure
Labs showed continued elevated BUN (5.3), Cr (5.0), and Potassium (5.3)
Order for bedrest and frequent monitoring d/t renal biopsy
Day 8 6/26
MD discussed with pt the need for dialysis, leaning towards PD
Potassium remains elevated (5.4) and Cr elevated but stable (5.0)
On kayexalate for elevated K
Plans for catheter placement and education for PD

19. Clinical Course Day 9 6/27 Biopsy came back confirming renal failure
Labs continued to show elevated BUN (83), Cr (4.9), and Phos (6.5)
Clinical Nutrition consulted for education
Reviewed renal diet with pt
Plans to follow-up in nephrology on weekly basis for blood work
D/C

20. Labs

21. Labs

23. Second Admission
7/10-7/16

24. Clinical Course Day 1 7/10 Day 2 7/11
Came to ED with vomiting, diarrhea, confusion, and weakness
Home Meds: Kayexalate and Lasix
Transferred to the ICU
Day 2 7/11
On strict urine output monitoring
Started on Carb Control 250 GM Diet w/glucose checks 2x daily
Labs: Elevated BUN (66) and Cr (4.4)

25. Clinical Course Day 3 7/12 Day 3 Continued
Discussion of HD vs PD d/t previous surgeries and hernia
Discussed w/pt, prefers to try PD
CT scan planned for next day to evaluate hernia/site for catheter placement
Labs showed elevated BUN (66)
Day 3 Continued
Seen by Clinical Nutrition
PES Statement: Mild protein calorie malnutrition related to acute illness as evidenced by estimated PO intake of less than 50% of needs over 5 days and 5% weight loss in two months
Recommend Consistent Carb Diet with 70g Protein Restriction
Nepro BID

26. Clinical Course Day 4 7/13 CT done to evaluate the use of PD vs HS
Diet Changed to 3g Sodium, 70g Protein
Labs showed elevated BUN (77), Cr (4.8), and Potassium (5.3)
Day 5 7/14
Plans to see in OP setting for HD
Education given in regards to HD
Complaints of chest pain, EKG showed nothing

27. Clinical Course Day 6 7/15 Outpatient Timeline Discharged
7/18 Seen for Dialysis
Arteriovenous Fistula placed for HD in left arm

28. PD vs HD?

29. Peritoneal Dialysis Use of peritoneum in a person’s abdomen
Peritoneum used as the membrane through which fluid and dissolved substance are exchanged with the blood.

30. Hemodialysis
More common, uses a machine called a dialyzer to clean the patients blood
Access is needed through the blood vessels

31. Third Admission
8/4-8/24

32. Clinical Course Day 1 8/4 Day 2 8/5
Arrived to ED with complaints of abdominal pain and N/V x3 Days
Labs: Elevated BUN (43) and Cr (3.3) with decreased Sodium ( )
Day 2 8/5
Admitted to ICU
NGT placed, NPO diet
Suspected SBO d/t hernia
Continued N/V
Labs: Elevated BUN (30) and Cr (3.7) with decreased Sodium (131)

33. Clinical Course
Day 3 8/6
Output from NGT was 3.5 L
Plan for Small Bowel Follow Through (SBFT) today
Labs: Elevated BUN (35), Cr (3.9), and Phosphorus (6.1)
Seen by Clinical Nutrition
PES Statement: Inadequate oral intake related to SBO as evidenced by reported N/V, NPO status and last BM prior to admission
Recommended advancing diet within hours
If not, consider starting TPN
Day 1: Continuous TPN at 65 ml/hr, Dex 11.3%, AA 5.5%
Day 2: Continuous TPN at 65 ml/hr, Dex 22.6%, AA 5.5%, and NO LIPIDS

34. TPN Calculations Estimated fluid needs = 62.4 kg X 25 ml/kg = 1560 ml
Estimated kcal needs = 62.4 kg X 25 kcal/kg = 1560 kcal
TPN Rate = 1560 ml / 24 hrs = 65 ml/hr
Protein Needs = g/kg X 62.4 kg = g Pro (86 g Pro or 344 kcal from Protein)
NO LIPIDS (Pt with Egg allergy)
Dextrose Needs = 1560 kcal – 344 kcal = 1216 kcal from Dextrose = kcal / 3.4 g/kcal = 357 g Dex

35. TPN Calculations Continued
% Pro = 86g Pro / 1560 ml = 5.5% AA
% Dex = 353g Dex / 1560 = 22.6% Dex
GIR: 3.93 mg/kg/min
Day 1: 11.3% Dex, 5.5% AA at 65 ml/hr
Day 2: 22.6% Dex, 5.5% AA with NO LIPIDS at 65 ml/hr
Provides 1560 kcal (25 kcal/kg), 86g Pro (1.37 g/kg), and GIR of at goal

36. Clinical Course Day 4 8/7 Day 5 8/8 Emesis overnight Diet NPO
Continued high output from NGT (1 L)
SBFT showed no transition into colon
Possible surgery today
Labs: BUN 31, Cr 5.0, Phos 5.5
Day 5 8/8
Continued HD
Diet: NPO x 5 Days
Placed on Add-On list for surgery today
Seen by Clinical Nutrition
Labs: BUN 39, Cr 5.7, Phos 5.4

37. Clinical Course Day 5 Continued
PES Statement: Severe protein calorie malnutrition related to SBO as evidenced by 4.6% weight loss in 6 days and NPO diet (meeting less than 50% of estimated needs) for 5 days since admission
Recommend TPN
Day 1: Continuous at 65 ml/hr, Dex 11.3%, AA 5.5%
Day 2: Continous at 65 ml/hr, Dex 22.6%, AA 5.5%, NO LIPIDS

38. Clinical Course Day 6 8/9 Day 7 8/10 Surgery done Given dilaudid
Laparotomy, exploratory bowel resection, hernia repaired
Given dilaudid
Diet: NPO
Labs: BUN 21, Cr. 3.9, Phos 3.5
Day 7 8/10
Pt experiencing tachycardia
Believed to be d/t inadequate fluids
Diet: NPO
Labs: BUN 31, Cr 4.8, Phos 4.3

39. Clinical Course Day 8 8/11 Day 9-10 8/12-8/13 Diet advanced to CL
Continued nausea
On pain meds (fentanyl patch) but still complains of 10/10 pain
Labs: BUN 18, Cr 3.8, Phos 3.3
Day /12-8/13
Diet changed to CL, Carb Control, Renal Diet
PO intake poor
Seen by Clinical Nutrition
Continue to recommend TPN or use of Nepro once diet advances
Labs: BUN 27-42, Cr , Phos

40. Clinical Course Day 11-13 8/14-8/16 Day 14 8/17 Episodes of N/V
NGT output on average was 1.5 L
Placed back on NPO
Labs: BUN 25-46, Cr , Phos
Seen by Clinical Nutrition
Continued recommendations for TPN
Discussed with nephrology
Day 14 8/17
TPN started at Day 1: Continuous at 65 ml/hr, Dex 11.3%, AA 5.5%
NGT continued high outputs
Labs: Elevated BUN (50) and Cr (5.2), both trending upward since 8/13, Phos 4.0

41. Clinical Course Day 15 8/18 Day 16-18 8/19-8/21
TPN advanced to goal of Continuous at 65 ml/hr, Dex 22.6%, AA 5.5%
NGT discontinued
No BM at this point
Day /19-8/21
Continued TPN at goal
Diet advanced to regular to promote PO intake
Poor PO intake, but no N/V, BM starting to occur
Labs: BUN (32) and Cr (2.9) trending down

42. Clinical Course Day 19-22 8/22-24 PO intake improved every day
TPN stopped on 8/19
No N/V
Diet: Low Residue w/ Nepro BID
Discharged on 8/24

43. Labs from 8/4-8/20

44. Labs from 8/4-8/20

45. Labs from 8/4-8/20

47. Evaluation/Reassessment
Pt currently at home, receiving HD 3x per week
Recommended that pt continue Nepro at home d/t wt loss during admission
Plans discussed with dialysis RD

48. Questions?

49. Thanks!

50. References
Gross, Jorge. Diabetic Nephropathy: Diagnosis, Prevention, and Treatment. American Diabetes Association. 28 Jan Accessed 30 Aug
Holley, Jean. Peritoneal Dialysis Versus Hemodialysis: Risks, Benefits, and Access Issues. University of Illinois, 1 Nov %2811% &doi= %2Fj.ackd Accessed 25 Aug
Small Bowel Obstruction. Cleveland Clinic. 17 June obstruction. Accessed 27 Aug
Wolfram, Taylor. What is Malnutrition. Eat Right, 18 Sep malnutrition. Accessed 25 Aug