1. Renal Mini Case Study By Melissa Jakubowski

2. Patient Information Initials: M.H. Female 72 years old Full code NKFA 1 st date of chronic HD Tx: 8/10/2010 1 st date of Tx at Fresenius: 8/20/2010

3. Socioeconomic/Family Status Retired Lives at home with husband Husband prepares meals Denies alcohol/illicit drug use H/o of smoking, quit 35 years ago

4. Anthropometric Data Height: 62” Weights: EDW: 54.50kg (119.9 lbs.) Pre-weight: 55.80kg (122.8 lbs.) Post-weight: 54.30kg (119.5 lbs.) No recent weight gain/loss BMI: 22.0 (LBW) IBW: 131-158 lbs. 91.5% IBW IDWG: 1.3kg

5. Interdialytic Weight Gain IDWG Recommendations: <3kg on weekdays <4kg on weekends Or <5% of EDW Equals 2.7kg for this patient IDWG: 1.3kg

6. Biochemical Data Lab ValueCurrent Value Hemoglobin10.9 Hematocrit34.9 ↓ Potassium4.6 BUN65 Creatinine5.8 Calcium9.4 Corrected Calcium9.8 ↑ Phosphorus4.4 Albumin3.5 ↓ Parathyroid Hormone (PTH)189.1

7. Abnormal Lab Values Lab ValueCurrent ValueNutritional Significance Hematocrit34.9 ↓ CKD → decreased EPO Corrected Calcium9.8 ↑ Low albumin Albumin3.5 ↓ ???

8. Serum Albumin History

9. Admitting Diagnosis DiagnosisPathophysiology ESRD (on HD) secondary HTN Hypertensive nephropathy & nephrosclerosis Lupus (SLE) Kidney mass

10. Past Medical History PMHPathophysiology CAD HTN, h/o smoking, older age, dietary habits MI CAD PTCA Surgical treatment of CAD HTN High sodium diet, h/o smoking, CKD Lupus Unknown; possibly hereditary 2cm Right Kidney Mass H/o smoking, HTN Contrast neuropathy Renal insufficiency, specifically ↑ creatinine

11. HD Access Left AV Graft Cath Placements Right AV fistula Infection Temporary Currently

12. Medications MedicationIndication Aspirin (acetylsalicylic acid) Prevention of blood clots Pain (neuropathy) & inflammation (Lupus) Lopressor (metoprolol) HTN Prednisone (corticosteroid) Lupus Zocor (simvastatin) Hyperlipidemia Renagel (sevelamer HCl) ESRD re: serum P levels Fish oil (omega-3 fatty acids) Hyperlipidemia Nexium (esomeprazole) ↓ s risk for gastric/duodenal ulcers

13. Prednisone Side Effects ↑ N urinary excretion Induces negative nitrogen balance Pathophysiology of low albumin

14. Abnormal Lab Values Lab ValueCurrent ValueNutritional Significance Hematocrit34.9 ↓ CKD → decreased EPO Corrected Calcium9.8 ↑ Low albumin Albumin3.5 ↓ Prednisone

15. Zocor Patient Education Avoid/limit grapefruit and other citrus fruits which inhibit the liver enzymes responsible for metabolizing Zocor

16. Supplements Dialyvite: Renal MVI, primarily containing B- complex vitamins, folic acid, essential minerals Vitamin C: limited to 60- 100mg/day to avoid formation of calcium oxalate kidney stones Protein supplement 3x/week (Nepro or Zone Bar)

17. Nutrition Needs CalorieProtein 30-35kcal/kg: 1600-1900 Harris-Benedict: 1500 Mifflin-St. Jeor: 1000 1.2-1.3g/kg: 65-71g

18. Fluids Fluid restriction of 1500mL (standard restriction for HD patients that produce < 1 L of urine/day) 1500mL = 50 fl. oz.

19. Current Dietary Recommendations ↑ protein diet (65-71 g/day) P restriction (800-1200 mg/day) K restriction (2000 mg/day) Na restriction (1500-2000 mg/day) Fluid restriction (1500 mL/day)

20. PES Statement Increased protein, calorie, and vitamin & mineral needs related to ESRD on HD as evidenced by LBW (BMI = 22) and low serum albumin (3.5g/dl)

21. Interventions Nutrition Rx: continue as recommended Protein supplement: continue as ordered Dialyvite & P-binder: continue as prescribed Encourage intake of high biological value (HBV) protein foods (eggs, meat, poultry, fish) Continued HD diet education

22. Goals To be achieved by next follow-up (48 hours): Lab (alb): to trend toward standard EDW: stable IDWG per standards Pt. to report: Dietary adherence to nutrition rx 100% supplement intake Oral intake amount per her normal; good appetite MVI and P-binder taken daily as prescribed

23. Monitoring/Evaluation  Labs, especially K, P, Ca, Alb, PTH  Pt. self-report: oral supplementation intake, oral intake/appetite, and GI Sx  Level of the knowledge: continued verbalization of nutrition rx  Weights (EDW, pre-weight, post-weight) to determine IDWG and assess adherence to fluid restriction and dialysis sufficiency  Change in medical history, especially regarding the kidney mass

24. Questions???