1. Renal Cell Carcinoma Case Study Presented by Erin McLean

2. Overview Patient information Disease background Nutrition care process Conclusion Review of key points Personal impressions

3. Patient Profile Gender: Male Age: 70 Ethnic background: Hispanic Household situation: Lives with wife, has 2 grown children living elsewhere Education: Not disclosed Occupation: Retired heavy equipment operator Religion: Not disclosed Admit date, discharge date: 09/03/13, 09/14/13

4. Reason for Hospital Admission The patient was admitted to the hospital for reparative surgery of a fractured right hip due to a nonsyncopal fall. Shortly before the patient fractured his hip, he was diagnosed with metastatic RCC. A x-ray exam found metastatic lesions in the area of the fracture.

5. Medical/Health/Family History Past medical history: –Stage IV RCC s/p 2 chemotherapy treatments –Type 2 diabetes with neuropathy –Hypertension –Hyperlipidemia –Peripheral vascular disease –Benign prostatic hyperplasia –Chronic kidney disease stage III

6. Medical/Health/Family History Home medications: –Enalapril, Megace, metformin, Norco, Reglan, iron, omeprazole, tamsulosin, fluoxetine Quit smoking 9 months prior to admission No history of alcohol or illicit drug abuse Poor appetite Family history positive for type 2 diabetes

7. Medical Diagnosis Pathologic fracture in the right femoral neck 2° metastatic RCC Pathologic fracture in the right proximal humerus 2° metastatic RCC Acute-on-chronic renal failure

8. RCC Defined RCC: –Most common form of kidney cancer –14 th most common form of cancer in US –Highly vascularized malignancies –Originates in lining of proximal convoluted tubules –Termed metastatic RCC when its spreads

9. RCC Defined

10. Pathophysiology RCC consists of various tumor groups: –Clear cell, 60-70% –Papillary, 5-15% –Chromophobe, 5-10% –Oncocytic, 5-10% –Collecting duct, <1%

11. Pathophysiology RCC affects calcium homeostasis:

12. Symptoms/Clinical Manifestations RCC often presents with symptoms unrelated to renal cancer. The 3 classical RCC symptoms include: –Abdominal pain, hematuria, palpable mass Metastatic RCC presents with: –Bone pain, pulmonary issues, adenopathy, GI bleeds

13. Etiology Risk factors for RCC: –Tobacco smoking –Obesity –Hypertension –Chemical exposure –Analgesic drug use –Hepatitis C infection –End-stage renal disease

14. Hypertension and Risk of Renal Cell Carcinoma Among White and Black Americans Purpose: –To determine the association between high blood pressure and RCC risk for black and white Americans Methods: –358 black and 843 white case participants –519 black and 707 white control participants –HTN history and antihypertensive drugs reported –ORs and CI calculated utilizing unconditional logistic regression Adjusted for smoking, BMI, family history of RCC, demographic characteristics (Colt et al., 2011, p. 1-4)

15. Hypertension and Risk of Renal Cell Carcinoma Among White and Black Americans Results: –In study population, HTN doubled risk of RCC –Whites had lower incidence of developing RCC (P=0.11) –RCC risk ↑ with passing years after initial dx of HTN with an OR of 4.1 (CI=2.3-7.4) for blacks and an OR of 2.6 (CI=1.7-4.1) for whites (P for trend <0.001) (Colt et al., 2011, p. 1, p. 4-5)

16. Hypertension and Risk of Renal Cell Carcinoma Among White and Black Americans Conclusion: –Among blacks and whites, HTN is a risk factor for RCC. –Due to the increased prevalence of high blood pressure in blacks than whites, HTN may explain the racial disparity of RCC incidence seen more commonly in the former rather than the latter group. (Colt et al., 2011, p. 1, p. 5-7)

17. Treatment Treatment depends on: –Type of RCC –Stage of RCC –Tissue or organs affected –Preexisting conditions or comorbidities –Nutritional status –Age

18. Treatment Surgical interventions: –Nephron-sparing partial nephrectomy –Radical nephrectomy –Laparoscopic nephrectomy

19. Treatment Immunotherapy: –Interleukin-2 –Interferon Tumor ablation therapy: –Cryoablation –Interstitial radio frequency ablation

20. Treatment Targeted therapy: –Sorafenib, pazopanib, sunitinib, everolimus Chemotherapy and radiotherapy

21. Treatment Treatment specific to patient: –Repair of right femoral neck fracture Right hip long stem hemiarthroplasty with cement – Repair of right proximal humerus fracture Intramedullary fixation

22. Treatment Medications: –Amlodipine, cefazolin, enalapril, fluoxetine, heparin, insulin, Megace, omeprazole, pantoprazole Patient had received 2 chemotherapy treatments prior to admission

23. Treatment Drug-nutrient interactions: –Fluoxetine — if taken with tryptophan supplements, can ↑ drug side effects –Omeprazole — can ↓ calcium absorption by 61%; if taken with gingko and St. John’s wort, can ↓ drug effectiveness (Pronsky & Crowe, 2010, p. 140, p. 260).

24. Nutrition Intervention Interventions implemented to combat following side effects associated with advanced cancer: –Nausea/vomiting –Weight loss –Early satiety –Anorexia –Xerostomia –Altered taste –Bloating –Constipation –Dysphagia

25. Fruit, Vegetables, Fibre and Micronutrients and Risk of US Renal Cell Carcinoma Purpose: –To determine if an association existed between the risk of RCC and the intake of fruit, vegetables, fiber, and certain micronutrients Methods: –323 case participants –1,827 control participants –Questionnaires with dietary intake of participants mailed to researchers for analysis (Brock et al., 2011, p.1077-1078)

26. Fruit, Vegetables, Fibre and Micronutrients and Risk of US Renal Cell Carcinoma Results: –Intake of vegetables ↓ RCC risk (P for trend =0.002) –Vegetable fiber associated with ↓ RCC risk (P<0.001) –Grain and fruit fiber had no association with ↓ RCC risk –β-cryptoxanthin ↓ RCC risk (P for trend =0.01) –Lycopene nonsignificantly ↓ RCC risk (Brock et al., 2011, p.1077, p.1079)

27. Fruit, Vegetables, Fibre and Micronutrients and Risk of US Renal Cell Carcinoma Results cont.: –Association between RCC risk and intake of vegetable fiber and β-cryptoxanthin stronger in those ≥65 years of age (P for interaction =0.001) –Nonsmokers with low intake of fruit fiber and cruciferous vegetables had ↑ RCC risk (P for interaction =0.03) Conclusion: –Further research necessary to identify additional nutritional compounds that ↓ RCC risk (Brock et al., 2011, p.1077, p. 1079, p.1082-1083)

28. Prognosis Prognosis dependent on cancer stage and method of treatment RCC Stage 5-Year Survival Rate Stage I 81% Stage II 74% Stage III 53% Stage IV, metastatic 8%

29. Prognosis Survival predictors that indicate a ↓ life expectancy include: –↑ serum calcium –↑ lactate dehydrogenase –Anemia –Stage IV RCC –↓ activities of daily living –Systemic treatment <1 year after diagnosis

30. Preoperative Nutritional Status Is an Important Predictor of Survival in Patients Undergoing Surgery for Renal Cell Carcinoma Purpose: –To determine whether nutritional deficiency is a critical factor in determining survival after surgery Methods: –369 patients who had either a partial or radial nephrectomy –85 patients considered nutritionally deficient preoperatively (Morgan et al., 2011, p. 923-924)

31. Preoperative Nutritional Status Is an Important Predictor of Survival in Patients Undergoing Surgery for Renal Cell Carcinoma Methods cont.: –Considered nutritionally deficient if: ≥5% body weight lost preoperatively BMI of <18.5 kg/m2 Albumin <3.5 gm/dL –Primary outcomes included overall mortality and disease-specific mortality (Morgan et al., 2011, p. 923-924)

32. Preoperative Nutritional Status Is an Important Predictor of Survival in Patients Undergoing Surgery for Renal Cell Carcinoma Results: –3-year overall survival was 58.5% and disease-specific survival was 80.4% in experimental group –3-year overall survival was 85.4% and disease-specific survival was 94.7% in control group –(P<0.001) (Morgan et al., 2011, p. 924-926)

33. Preoperative Nutritional Status Is an Important Predictor of Survival in Patients Undergoing Surgery for Renal Cell Carcinoma Conclusion: –Addressing poor nutritional status in RCC patients undergoing surgery is essential since it remains a significant predictor of overall and disease-specific mortality. (Morgan et al., 2011, p. 923, p. 927)

34. Nutrition Care Process

35. Assessment Anthropometric data: –Height: 5’11” –Weight: 72.3 kg –IBW: 78.2 kg ±10% –BMI: 22.2 kg/m2, normal

36. Assessment Biochemical labs: Renal Profile Date09/0409/0809/0909/1009/1109/1209/13 Glucose (mg/dL) 119, High177, HighNormal112, HighNormal134, High139, High BUN (mg/dL) Normal Creatinine (mg/dL) Normal1.55, High1.35, High1.26, HighNormal Potassium (mEq/L) Normal 3.1, LowNormal 3.3, LowNormal Chloride (mEq/L) 113, High116, High118, High 114, High112, High111,High CO2 (mEq/L) 14, Low12, Low13, Low16, Low 17, Low Calcium (mg/dL) 6.8, Low 6.6, Low6.4, Low6.3, Low6.2, Low Albumin (gm/dL) 1.6, Low1.5, Low 1.4, Low1.5, Low Phosphorus (mg/dL) 2.1, Low Normal1.7, Low2.0, Low2.1, Low2.0, Low GFR (mL/min/1.73 m2) Normal45, Low52, Low57, LowNormal

37. Assessment Biochemical labs cont.: Basic Metabolic Panel (BMP) Date09/0509/0609/0709/08 Glucose (mg/dL) 173, High154, HighNormal166, High BUN (mg/dL) Normal Creatinine (mg/dL) 1.42, High1.47, High1.55, High1.56, High Sodium (mEq/L) 135, LowNormal Potassium (mEq/L) 3.4, Low 3.0, LowNormal Chloride (mEq/L) 114, High119, High121, High120, High CO2 (mEq/L) 14, Low13, Low15, Low12, Low Calcium (mg/dL) 7.0, Low6.9, Low7.3, Low6.9, Low GFR (mL/min/1.73 m2) 49, Low47, Low45, Low44, Low

38. Assessment Biochemical labs cont.: Comprehensive Metabolic Panel (CMP) Date09/14 Glucose (mg/dL) 207, High CO2 (mEq/L) 17, Low Calcium (mg/dL) 7.3, Low Total Protein (gm/dL) 5.9, Low Albumin (gm/dL) 1.8, Low

39. Assessment Complete Blood Count (CBC Complete Blood Count (CBC) Date09/0409/0509/0709/0809/0909/1009/1109/1209/1309/14 Red Blood Cell (m/ul) 3.70, Low4.32, Low4.33, Low4.14, Low4.09, Low3.89, Low3.90, Low3.85, Low4.04, LowNormal Hemoglobin (gm/dL) 7.8, Low9.9, Low10.3, Low10.0, Low9.7, Low9.2, Low 9.1, Low9.4, Low10.5, Low Hematocrit (%) 25.0, Low30.4, Low30.9, Low29.6, Low29.4, Low27.6, Low27.8, Low27.4, Low28.5, Low31.9, Low Biochemical labs cont.: Other Labs Date09/0409/0509/0609/0709/09 Ionized Calcium (mmol/L) 1.00, Low0.98, Low 1.06, LowNo lab drawn PTH, Intact (pg/mL) No lab drawn 101, High Vit D, 25-OH (nmol/L) No lab drawn 17, Low

40. Assessment Diet history: –Poor appetite –General diet at home –No swallowing difficulties –No issues with digestion/elimination

41. Assessment Dietary consult #1: –Sent by MD to address patient’s malnutrition status before initial surgery –Consult sent based on patient’s low albumin labs (1.5-1.8 gm/dL throughout stay) –Per daughter, patient consumed <50% of each meal

42. Assessment Calculated needs: –Calories 2170-2530 kcal (30-35 kcal/kg ABW) –Protein 94-108 gm/day (1.3-1.5 gm/kg ABW) –Fluid 2170-2530 ml/day Level 2 nutritional compromise: –Limited PO intake (<50%) –Unintentional weight loss PTA

43. Nutrition Diagnoses PES statements: –Inadequate energy intake related to current condition as evidenced by intake record. –Increased nutrient needs related to metabolic stressors as evidenced by albumin.

44. Nutrition Intervention Nutrition intervention: –Glucerna Snack Shake TID (420 kcal) –Mighty Shake TID (384 kcal) –Encouraged to order from room service menu –Request to MD to liberalize diet –Continue Megace (400 mg BID) and calcium gluconate

45. Monitoring & Evaluation Monitoring and evaluation: –Patient’s serum albumin labs would trend towards normal limits –Patient would meet >75% of estimated nutritional needs from oral food intake –Lean body mass would remain intact

46. Assessment Dietary consult #2: –Sent by MD to address increasing calcium in the patient’s diet –Consult sent based on patient’s low ionized calcium labs (0.98-1.06 mmol/L) –Per daughter, patient consumed ~50% of each meal

47. Assessment Calculated needs remained the same Level 2 nutritional status remained the same Nutrition diagnoses remained the same

48. Nutrition Intervention Nutrition intervention: –Continue Glucerna Snack Shake TID –Discontinue Mighty Shake TID –Propass with mousse BID –Request to MD for vitamin D and PTH labs –Continue Megace (400 mg BID), calcium gluconate, vitamin C (500 mg/day), and multivitamin (1 tablet per day)

49. Monitoring & Evaluation Monitoring and evaluation: –Patient’s ionized calcium labs would trend towards normal limits –Patient’s serum albumin labs would trend towards normal limits –Patient would meet >75% of estimated nutritional needs from oral food intake –Weight would remain stable –Lean body mass would remain intact –Promotion of surgical wound healing

50. Assessment Follow-up/reassessment: –Patient reported improvement in appetite –Per patient, consuming 50-75% of each meal Calculated needs remained the same Level 2 nutritional status remained the same Nutrition diagnoses remained the same

51. Nutrition Intervention Nutrition intervention remained the same but with two additions: –Vitamin D supplementation –Re-instate calcium supplementation

52. Monitoring & Evaluation Monitoring and evaluation remained the same but with one addition: –Patient’s vitamin D labs would trend towards normal limits

53. Conclusion Patient admitted for surgical repair of right hip fracture Additional fracture found in right proximal humerus Patient developed AoCRF which resolved upon discharge Medical diagnosis: Pathologic fractures Nutritional diagnoses: Inadequate energy intake and increased nutrient needs

54. Conclusion Nutrition interventions: –↑ overall food intake –Treating nutrient deficiencies Upon discharge, albumin increased slightly Calcium supplementation not re-instated Vitamin D supplements ordered Weight could not be monitored after 2 nd consult

55. Review of Key Points RCC most common form of kidney cancer Highly vascularized malignancies Affects calcium homeostasis Classic symptoms include: –Abdominal pain –Hematuria –Palpable mass

56. Review of Key Points Most prominent risk factors include: –Smoking –Obesity –Hypertension Many treatments available including: –Surgical interventions –Immunotherapy –Tumor ablation therapy –Targeted therapy

57. Review of Key Points Nutrition interventions typically combat nutrition-related side effects Prognosis dependent on cancer stage and method of treatment

58. Personal Impressions

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