Stacy Cliff ESRD Case Study

1. Why does RS need dialysis? RSs medical history reveals he is both diabetic and hypertensive. These comorbidities are the most common cause of kidney failure.1 Diabetes, hypertension, along with other diseases that affect the vascular system can impair the kidneys ability to filter the blood and regulate bodily fluids. When you have diabetes the small blood vessels in the kidneys can be injured. When this happens the kidneys cannot efficiently clean your blood, resulting in water and salt retention. Diabetes can also cause nerve damage. Nerve damage can result in difficulty emptying the bladder. If urine stays in the bladder for a long time it can back up and injure the kidneys. Infection from bacteria growth in a full bladder is also detrimental to kidney function and health. There are 5 stages of chronic kidney disease, with kidney function getting progressively worse. Stage 5 is end stage renal disease (ESRD) which is fatal unless dialysis is performed frequently or a kidney transplant is recieved.2

2. Why HD over PD? Healthy kidneys clean the blood by removing waste products and excess fluid from the body. When the kidneys stop functioning, metabolic waste and excess fluid build-up. Hypertension can be exacerbated due to increased fluid volume resulting in detrimental consequences to the cardiovascular system. Non-functioning kidneys will also fail to produce hormones and adequate red blood cells. When kidneys fail, treatment is necessary to mimic kidney function. Hemodialysis (HD) and peritoneal dialysis (PD) are dialysis options available to patients suffering from ESRD. During hemodialysis (Fig. 1) blood is allowed to flow from the body through a filter located in a dialysis machine operating like an artificial kidney. After waste and extra fluid is removed, the clean blood is returned to the body. ESRD patients electing HD must follow a strict dialysis schedule consisting of three or more days a week for three to five hours each time.3 This intensive schedule would have a negative effect on career aspirations, finances, self-esteem, and level of independence of HD patients. Home dialysis is also an option that is becoming more popular. A family member or

friend must be committed to taking the necessary training along with the patient. A strict schedule must still be adhered to for successful treatment.

Fig. 13 Hemodialysis

Fig. 24 Peritoneal dialysis

There are several forms of peritoneal dialysis (PD) allowing for more, or less, freedom of movement depending. Regardless of ambulatory properties all PD options work by filling the abdominal cavity with a solution containing dextrose. This fluid collects waste and extra fluid from the blood and is then disposed of. The filling and draining of the fluid is called the exchange and takes around 30 minutes. The time the solution sits in your abdominal cavity is called the dwell time. A typical schedule is 4 exchanges with 4-6 hours of dwell time each exchange.4 Other forms of PD can be completed while you sleep, or continuous ambulatory PD which does not require a machine and you can go about your day with the dialysis solution in your abdominal cavity. PD affords patients greater autonomy but a higher level of patient involvement is required. Making the decision about which treatment to receive can be difficult, and the reasons one is chosen over the other is unique to the individual. In the study by Sinnakirouchenan et al,5 researchers found that 83% of patients surveyed reported their physician was important in influencing what method they chose. PD patients said they depended more on written material and spouse or significant others opinion. Autonomy and control were important for 95% of those choosing PD. The three most

cited reasons for choosing PD included: 1) flexibility of schedule, 2) convenience of performing PD in their own home and 3) option of doing it while sleeping. Those that selected HD cited 1) desirability of having a planned schedule and 2) letting nurses take care of them. In this study it would seem the PD patients have an internal locus of control whereas the HD patients have an external locus of control. However in the article by Theofilou,6 in regard to patients internal beliefs about their current health condition, both HD and PD groups were comparable in their higher scores related to internal locus of control. This authors explains the higher value HD patients in internal locus by indicating it is probably the emphasis on their own behavior for control over their current health condition of health, perhaps a counterbalance for feelings of dependence on the machine.6 In this study PD patients gave more importance to the function of medical professionals than those electing HD. Theofilou explains that this could be related to their dependence on doctors to train them in the PD procedure. HD patients reported less community and social support, therefore were used to self-reliance. Yet, when compared to PD, HD patients negatively evaluated many aspects of their environment including: the quality and availability of health services, transportation, finances, learning opportunities and free time. In my opinion, they are negatively rating things that can be changed, therefore not taking responsibility for the consequences of their health condition. This would seem like the musings of patients with higher external locus scores. Orhan et al7 reports that HD patients had low scores on a scale of selfdirectedness. This quality is related to the qualities of immaturity, weakness, ineffectiveness, blaming, irresponsibility and unreliability. The authors state that they are lacking an internal organizational principle which makes it unlikely they will define or accomplish goals. Importantly in the case of HD, patients scoring low in selfdirectedness are not expected to overcome obstacles or positively influence an adverse situation. In this study, PD patients self-directedness scores were not different than the control group. Both HD and PD patients had similar levels of depression. In reviewing this literature I have noticed conflicting reports on personality traits of both HD and PD patients related to the therapy they choose. ESRD and dialysis is an enormous life altering situation. The way people will handle diagnosis and treatment

will probably change as they progress through different stages of grief, depression, and acceptance. RS had PD in the past. He has since had the catheter removed, choosing HD currently. I think HD is a good choice for him now. His diet management is poor and he is suffering from comorbidities resulting in hospital stays. He was found unconscious by his girlfriend recently and suffered mental confusion from a fall as well. I think the accountability of the center visits are important right now. If he fails to make an appointment someone will check up on him. If he were to suffer another fall or syncope he might not receive prompt medical attention if no one is expecting him.

3. Risk of malnutrition for maintenance HD patients Malnutrition is common and is strongly associated with greater risk of mortality in HD patients.8 In order to prevent malnutrition, psychological problems including depression shown to be associated with lack of appetite should be identified according to research by Lopes et al.9 Results of this study suggest that mean values of albumin, creatinine, nPCR and BMI decreased as lack of appetite increased. WBC and neutrophil count increases are strongly correlated with increased degrees of being bothered by a lack of appetite. Patients who experience a lack of appetite showed a significant increase in mortality and hospitalizations. Those who reported only that they were somewhat bothered by lack of appetite had a 21% higher mortality risk and a 12% higher risk of being hospitalized. Hospitalization risk was also independently associated with lack of appetite. The odds of a patient suffering from depression and protein malnutrition was positively correlated to lack of appetite. HD patients who had longer dialysis sessions were associated with having decreased occurrences of being bothered by lack of appetite. It is important to identify malnutrition to ensure the effectiveness of dialysis. In the Clinical Practice Guidelines10, it is recommended to increase the minimally adequate dose of dialysis for those who are malnourished. Changing to a more frequent dialysis schedule could accomplish this and is recommended for patients whose weights are 20% lower than their peer weights or patients with recent or unplanned weight loss. Nutritional counseling may help to prevent the occurrence of malnutrition by helping

HD patients with poor appetites and/or nausea choose foods that are suitable for their appetite and to meet nutritional requirements.9 RS has recently experienced an unplanned weight loss of 9 pounds (%15). During his first hospital stay his meal completion was recorded by the dietitian to be 050%. This certainly alludes to a lack of appetite. During his second stay he saw some improvement, completing 25-75% of his meals. A calorie count showed he was only taking in an average of 55% of his caloric recommendation. A concern over his nutritional status was shown and Nephro was ordered. Adequate dietary protein is needed to prevent protein energy malnutrition. RS will be advised to eat 1.2g/kg-body weight per day. At least 50% of this should be high biological value protein from animal sources.11 If an increased need for protein is suggested due to concerns about malnutrition then it is even more important for RS to take phosphorus binders as prescribed because protein food sources are also sources of phosphorus. Malnutrition (NI 5.2; Nutrition Intervention of Nutrition Care Process)36

4. Why were dry weights recorded and what do they reflect for RS? Dry weight is the patients weight after a dialysis session when all of the extra fluid in their body had been removed. It is what a normal person would weigh after they urinate. A true dry weight is defined as the weight at which a patients fluid status is optimal. An accurate true dry weight is important to obtain so clinicians will know if an adequate volume of fluid has been removed during treatment. Clinicians will weigh the patient before dialysis and compare that number to the usual dry weight, the difference between the two will be the volume of fluid they need to remove. The volume status of a patient is a function of their sodium and water intake, urine output, and the removal of excess fluid by ultrafiltration during dialysis. If inadequate fluid is not removed, the excess volume can contribute to hypertension and cardiovascular complications. Therefore, accurate dry weight is essential for effective dialysis and prevention of comorbidities. A study by Agarwal et al12, concluded that accurate measures of dry weight in patients with ESRD can potentially benefit patient with cardiovascular disease. It also suggests that achievement of dry weight can improve blood pressure during dialysis, reduce pulse pressure, and limit hospitalizations. This could prove important in RSs

dialysis routine. He is hypertensive, has congestive heart failure and has recently spent over three months in a hospital and sub-acute rehabilitation facility. 5. Calculate estimated energy11 and nutrition11 needs for RS. For protein needs I am using RSs normal body weight of 58kg. Due to his recent hospitalizations and weight loss I am concerned about the adequacy of his protein intake. We do not have height information for RS so I am unable to determine his BMI. In my opinion, 58kg for a 63 year old male is underweight to normal. Serum albumin is an indicator of visceral protein mass and has been used to assess nutritional status in patients with ESRD. Since RS has consistently low albumin levels I am proceeding as if he is not overweight or obese, and giving nutritional recommendations based on 58kg being his IBW. It is important to get RSs height so we can determine if he is underweight at 58 kg and needs even more protein and energy in his diet.

Protein= kg body weight x 1.2g Protein= 69.6 grams of Protein Energy needs= I am using the K/DOQI guidelines recommendations for adults over the age of 60 on dialysis: 30-35kcals x IBWkg = 35 x 58kg = 2030 Fluid needs= based on urine output plus 500 to 1000 mL per day, minimum fluid allowance is 1000 mL day Sodium= Less than 2.4g/day RS should limit sodium as much as possible because he is hypertensive. His recent pleural effusion could be the result of too much sodium in his diet resulting in fluid retention in the lungs. Potassium= Less than 2.4 g/day Phosphorus= 800-1000 mg/day Calcium= Not to exceed 2g Vitamin C= 60-100 mg/day Vitamin B-6= 2mg/day Folate= 1-5 mg/day Vitamin E= 15 IU/day Zinc= 15 mg/day

Meal Pattern: _70g _PRO 35g HBV PRO _<2.4g/day_ Na+ _<2.4g/day K+ _800-1000mg_Phosphorus _2030_kCal Food Group Starch Low K Fruit Med K Fruit Dairy Alt Milk Low K Veg Med K Veg Legume Meat Fat Fluid Total 7 2 32 0z 532 200 0 2031 49 0 0 79/49 0 0 0 244 36 10 0 67 455 110 0 2275 805 20 0 2045 525 10 0 1100 1.5 0 2 113 0 60 2 0 6 9 0 10 10 0 0 60 0 0 90 0 200 90 0 100 Servings 11 4 kCal 880 240 PRO 22 0 CHO 165 60 Fat 11 0 Na 1650 0 K 550 400 P 330 45

Starch

Fruit

Milk alt

Veg

Fluid (oz.)

Meat

Fat

CHO#

Bfast 9:00am Lunch 12:00pm Snack 3:00pm Dinner 6:00pm Snack 9:00pm

.5

48

50

.5

48

50

.5

48

Meal Breakfast

Menu Whole English muffin One egg Ounce soy cheese *Take phosphorus binder! 4 0z. Apple Juice 3 oz. Tuna 1 T mayo Lettuce *Take phosphorus binder! cup Carrots 2 slices white bread cup strawberries 8oz. water 1 bagel oz. soy cream cheese *Take phosphorus binder! Grapes (15) 8oz. water 1 cup rice 3 0z. shredded chicken *Take phosphorus binder 1 6in tortilla cup green peppers and onions 1 T. olive oil 8 oz water 3 cups popcorn 1 oz. soy shredded parm cheese *Take phosphorus binder 4 oz. apple juice -Take your phosphorus binder with every meal and snack -When measuring liquid remember to include water and anything that melts at room temperature (i.e. Jell-O)

Lunch

Snack

Dinner

Snack

Notes:

USDA nutrient database13 was source used for nutrient values.

6. Meal completion and nutritional needs for first hospital stay and recommendations following that dischargeRS was hypoglycemic at the time of first admission to the hospital. Hypoglycemia presents in someone with abnormally low blood sugar. Malnutrition can increase the risk of hypoglycemia, and as previously mentioned, malnutrition is significantly associated with a higher risk of mortality in HD patients like RS.8 Loss of consciousness is possible when a patient is experiencing extreme hypoglycemia. RSs loss of consciousness and mental confusion could be contributed to hypoglycemia. RS reportedly consumed 0-50% of meals during this first admission. This only exacerbated the concern over his nutritional status. RS is known to be non-compliant in his prescribed diet, therefore after the first discharge, his readmit was not surprising. His nutritional needs may not have been addressed, or he could have chosen to ignore the advice of

his medical team including the dietitian working with him. RS must consume his meals and snacks following a diabetic meal pattern. Meals should be at regular intervals with only 3 hours between them. He should consume around 50g of carbohydrates at each meal to keep his blood sugar level and prevent a hypoglycemic episode. It may be necessary to decrease the time between meals to 2 hours and add an extra snack. Once RSs height is obtained, we may be able to increase energy allotments to allow for weight gain. We also may be able to allow for more energy if RS resumes exercising after he receives physician approval to do so. RS has inadequate carbohydrate intake36, related to his not consuming enough carbohydrate at regular intervals according to a diabetic meal plan as evidenced by his hypoglycemia, mental confusion, and syncope.

His nutritional goal for this discharge could be to practice eating the diabetic meal plan and record his intake for review by a dietician.

7. Nutritional issues related to second hospitalization a. C. difficile colitisC. difficile is a bacteria that can cause swelling and irritation of the large intestine. This inflammation is known as colitis. Signs and symptoms include diarrhea, fever and abdominal cramping. RS contracted this bacteria during his second hospital admission. He presented with diarrhea which could have resulted in his poor appetite, and dehydration (not reported). His infection of C. Difficile could be partially responsible for his poor intake during this admission. Since abdominal cramping usually accompanies this infection and diarrhea, eating would be difficult and understandably avoided. Major risk factors related to C. Difficile infection are being older, other existing medical conditions and being in a hospital or long-term care facility. Other risk factors include: recently taking antibiotics, and underlying inflammatory bowel diseases. It has been suggested the use of proton pump inhibitors can also increase the risk of C. Difficile infection. RS is older, suffering from ESRD, hypertension, DM, hypothyroidism and heart failure. He is currently taking Protonix which is a proton pump inhibitor and he has recently spent over 3 months in a hospital and a rehabilitation facility.14

Since his dairy intake is limited due to concerns over high phosphorus levels, he cant eat yogurt to help replace the good bacteria in his gut after taking vancomycin. He should remember to take his probiotic to help replace the helpful bacteria he lost. b. Meal completion/intakeFor this second hospitalization, RS was consuming more of his meals which is good. He also began to take more of his Nepro supplement. He was consuming an average of 55% of his meals, which correlated with an actual intake of around 1116 kcal and 35g of
protein daily. This will result in protein malnutrition and weight loss. It is important to get his energy and protein levels up to the recommended amounts. According to K/DOQI recommendations oral supplementation is recommended if nutrient needs are not being met.

c. Discharge recommendations RS should strive to increase protein and continue taking his vitamin supplementation to decrease malnutrition. K/DOQI guidelines should continue to be followed to prevent
hypoglycemia and the diabetic meal plan should be adhered to. If RS continues to fail to achieve adequate nutrition and protein then K/DOQI guidelines would recommend the next step to be tube feeding, which RS assumedly wants to avoid.
11

8. Lab comments Lab Reference Number Albumin15 3.5-5 g/dL Patient Value (current) 2.55 (LOW)
Mortality risk is 1.38 times higher for patients with albumin levels less than 3.5g/dL. It is used to assess protein-energy nutrition status and monitor for malnutrition. A low albumin level is reflective or protein loss in urine.
Normalized protein catabolic rate. NPCR allows for a longitudinal analysis of the patients nutritional status. It can determine if the HD does should be increased due to a sustained high protein intake. Potassium affects how steadily your heart beats. Kidneys regulate the amount of potassium in the blood. Too much potassium in the blood can occur between dialysis sessions and can have negative implications on heart health. *See Calcium/PTH relationship below Low calcium is common in those with kidney failure.

Implication

nPCR9 Potassium16

>1g/kg/d

1 (GOOD)

3.5-5.5

4.3 (GOOD)

Adj. Calcium17 Phosphorus18

8.4-10.2

8.96 (GOOD)

3.5-5.5

3.3 (GOOD)

HgbA1c19 Cholesterol20

<7%

4.4%

80-200

106 (GOOD)

PTH17 Ferritin21,22

150-300

77.8 (LOW)

Phosphorus control is dependent on phosphorus intake, phosphorus-binder intake, and HD prescription. Level is a robust predictor of mortality in CKD patients. Phosphorus is a large molecule and difficult to remove through dialysis. Too much phosphorus in the blood causes calcium to be leached from bones making them weak and brittle. It can also lead to calcification of organs and deposits of calcium phosphate in tissues. His lab is low currently, but a history of noncompliance has been noted. This is likely low because he has been on a hospital prescribed diet, and it should be watched carefully as he returns home. In those diagnosed with both CKD and DM the A1c test is less reliable. Complications from these diseases, anemia and malnutrition can affect A1c results. Research suggests ESRD HD patients A1c results underestimate glucose levels. With RSs history of heart failure his cholesterol should be monitored regularly. High cholesterol, smoking, DM, hypertension are all risk factors of heart disease that RS currently has. Cholesterol plaque can clog the renal arteries, cutting off blood flow to the kidneys. *See Calcium/PTH relationship below Low levels of PTH may be due to conditions causing hyperkalemia or to an abnormality in PTH production causing hypoparathyroidism. Serum ferritin is an acute phase reactant and may be elevated in a number of conditions common to CKD patients, including infections, inflammation, malignancy, and liver disease. In the study by Rafi et al21, high serum ferritin did not necessarily mean iron overload, in study subjects it showed intermediate iron status. Conversely, in the study by Jairam et al22, ferritin values below 500 ng/ml were influenced by inflammation, but if markedly increased above that, it was more likely a result of iron overload and not just inflammation.

22-322

1496 (HIGH)

*Calcium/PTH relationship- These two tests are most often ordered together because it is the balance between them and the parathyroid glands response to the changing levels of calcium that is important. If both levels are normal it is likely the bodys calcium regulation system is

functioning properly. The following table is from lab tests online and shows the interpretation of different PTH and calcium levels17.

9. Medication table Medication Aspirin23 Indication/Class

To reduce the risk of death and nonfatal stroke with previous ischemic stroke or transient ischemia of the brain. To reduce risk of vascular mortality with suspected acute myocardial infarction (MI). To reduce risk of death and nonfatal MI with previous MI or unstable angina. To reduce risk of MI and sudden death in chronic stable angina pectoris. / Salicylate Treatment of mild-to-severe chronic heart failure of ischemic or cardiomyopathic origin /Alpha1/beta-blocker

Side Effects/Nutrient Interaction

May inhibit platelet function; can adversely affect inherited (hemophilia) or acquired (hepatic disease, vitamin K deficiency) bleeding disorders. Monitor for bleeding and ulceration. Avoid in history of active peptic ulcer, severe renal failure, severe hepatic insufficiency, and Na+ restricted diets. Associated with elevated LFTs, BUN, and SrCr; hyperkalemia; proteinuria; and prolonged bleeding time. Fever, hypothermia, dysrhythmias, hypotension, agitation, cerebral edema, dehydration, hyperkalemia, dyspepsia, GI bleed, hearing loss, tinnitus. Decreased diuretic effects with renal or cardiovascular disease. Increased effects of hypoglycemic agents. Antagonizes uricosuric agents. May enhance blood glucose-reducing effect of insulin and oral hypoglycemics; monitor blood glucose. Diabetes: Monitor glucose as -blockers may mask symptoms of hypoglycemia or worsen hyperglycemia. Monitor renal function during up-titration in patients with underlying renal insufficiency. Edema. Diarrhea. Worsening heart failure/fluid retention may occur. Severe exacerbation of angina if d/c suddenly. Caution with advanced renal impairment. D/C if glomerulonephritis occurs. Peripheral neuritis reported; add pyridoxine if symptoms develop. May cause angina.

Coreg24

Hydralazine25

Isosobide Dinitrate SR26 Lactobacillus27

(Tab) Essential HTN, alone or as adjunct. (Inj) Severe essential HTN when drug cannot be given PO or when there is an urgent need to lower BP / Vasodilator Prevention of angina pectoris due to coronary artery disease. / Nitrate vasodilator

Crescendo angina, rebound HTN. Additive vasodilation reported with other vasodilators. Suggested role in decreasing ammonia and excess cholesterol in blood. Renal failure associated with small intestinal bacterial overgrowth which compete for nutrients. They can use proteins in the lumen leading to protein deficiency.

/ Probiotic Blend

Synthroid28

Hypothyroidism, Pituitary TSH Suppression/ Thyroid replacement hormone

Nephro-cap29

Norvasc30 Protonix31

Wasting syndrome in chronic renal failure; uremia; impaired kidney metabolic functions and to maintain levels when dietary intake of vitamins is inadequate or excretion or loss is excessive / Vitamin supplement Treatment of HTN or coronary artery disease / Calcium channel blocker Short-term treatment in the healing and symptomatic relief of erosive esophagitis (EE) associated with GERD / Proton pump inhibitor

Probiotics can regulate bacterial overgrowth. May decrease bone mineral density (BMD) Caution in patients with diabetes mellitus (DM). Patients with diabetes mellitus may require upward adjustments of their antidiabetic therapeutic regimens. Overtreatment may produce CV effects including angina. May cause dyspnea, increased appetite. GI disturbances including: diarrhea, vomiting, abdominal cramps and elevations in liver function tests; May decrease absorption with soybean flour, cottonseed meal, walnuts, and dietary fiber. May decrease T4 absorption with antacids (aluminum & magnesium hydroxides), administer at least 4 hrs. apart. Consequences of over or under treatment effects on growth and development, cardiovascular function, bone metabolism, reproductive function, cognitive function, emotional state, gastrointestinal function, and on glucose and lipid metabolism. Decreases in TBG concentrations are observed in nephrosis. Increased pulse and blood pressure. Inform that the drug contains folic acid and may mask the symptoms of pernicious anemia.

Remeron32

Treatment of major depressive disorder / Piperazinoazepine

Renvela33

Control of serum phosphorus in patients with chronic kidney disease on dialysis / Phosphate binder

Ultracet34

Short-term (5 days) management of acute pain /

May cause symptomatic hypotension, particularly in patients with severe aortic stenosis. Worsening angina and acute myocardial infarction (MI) May increase risk of Clostridium difficile-associated diarrhea (CDAD), especially in hospitalized patients. Hypomagnesaemia reported and may require Mg2+ replacement and discontinuation of therapy; Atrophic gastritis noted with long-term therapy, particularly in patients who were Helicobacter pylori positive. Vitamin B12 deficiency caused by hypo- or achlorhydria may occur with long-term use. (IV) Thrombophlebitis reported. Contains edetate disodium, a chelator of metal ions including zinc; consider zinc supplementation in patients prone to zinc deficiency Increased appetite, weight gain, and elevation in cholesterol, TG, and ALT levels reported. Caution with hepatic/renal impairment, diseases/conditions affecting metabolism, and in the elderly. May cause orthostatic hypotension; caution with cardiovascular (CV) or cerebrovascular disease that could be exacerbated by hypotension (history of myocardial infarction, angina, or ischemic stroke) and conditions that predispose to hypotension (dehydration, hypovolemia). May cause serotonin syndrome with other serotonergic drugs (eg, triptans, TCAs, tramadol, tryptophan, buspirone, St. John's wort) and with drugs that impair metabolism of serotonin. Advise families and caregivers of the need for close observation for signs of clinical worsening and suicidal risks and to report such signs to physician. Monitor bicarbonate and chloride levels, and for reduced vitamins D, E, and K (clotting factors), folic acid levels and bowel obstruction and perforation, dysphagia, esophageal tablet retention, and bicarbonate and chloride levels. Caution in elderly patients. ADVERSE REACTIONS N/V, diarrhea, dyspepsia, abdominal pain, flatulence, constipation. Rare cases of increased TSH levels reported with levothyroxine; monitor TSH levels and for signs of hypothyroidism when used concomitantly. Reports of tramadol-related deaths in history of emotional disturbances, suicidal ideation/attempts, misuse of

Central acting analgesic

tranquilizers/alcohol/CNS active drugs. Development of serotonin syndrome including mental status changes, autonomic instability, neuromuscular aberrations, and GI symptoms reported. Assess for renal/hepatic impairment.

10. Indications and potential benefits of Nepro as prescribed for RS Nephrocaps are vitamin supplements containing: pantothenic acid, biotin, vitamin b12, folate, vitamin b6, niacin, riboflavin, thiamine, and vitamin C. The dialysis procedure removes large amounts of water-soluble vitamins which do not build up in the body and must be replaced daily from the diet including: vitamin C, B-complex vitamins and folic acid. Nephrologists feel that supplementation with a vitamin such as Nephrocaps is beneficial. This supplement has been designed to specifically replace nutrients lost during dialysis. It is important to warn patients about taking vitamin supplements off of store shelves, as they are poorly regulated and have nutrients such as electrolytes and phosphorus which must be closely monitored. According to the Davita website other vitamin supplements recommended are Nephro-Vite and Nephroplex.35 While a good diet can also usually keep up with these losses, many HD patients report lack of appetite. The addition of this vitamin complex is good nutrition advice to patients who are at risk of becoming malnourished due to dialysis treatment.

11. Nutrition diagnosis and intervention36 Diagnosis: R.S. has an excessive mineral intake history of phosphorus, related to his overconsumption of phosphorus containing foods and forgetting to take phosphate binders, also a probable lack of knowledge about management of his diagnosed disease state (ESRD) requiring the restriction of phosphorus, as evidenced by his phosphorus level in August of 10.6 mg/dL and his classification of non-compliant due to his history of out of control phosphorus levels. Intervention: The renal dietitian recommends a nutrition intervention and will include a lesson on avoiding foods containing high and moderate amounts of phosphorus. She will present helpful tips on looking for hidden phosphorus in the form of phosphate salts in processed foods and as phosphoric acid in dark colored sodas like Coke and Pepsi. Since R. S. is out of the hospital and is expected to return to his normal eating habits, this intervention will take place in one week at his scheduled appointment after dialysis. R.S. will be encouraged to set a goal for a lower phosphorus number on his next lab. He will also be encouraged to set a goal of remembering to take his phosphate binder with his meals. The dietitian will present helpful tips on how to remember to do this, such as set an alarm on his phone to go off every day at the same time reminding him. References:

1. Kidney and Urinary Tract Function, Disorders, and Diseases. Lab Tests Online. Web site http://labtestsonline.org/understanding/conditions/kidney/start/1. Revised November 15, 2013. Accessed November 29, 2013. 2. National Kidney Disease. Diabetes and Kidney Disease. Web site. http://www.kidney.org/atoz/content/diabetes.cfm. Updated 2013. Accessed November 29, 2013. 3. US Department of Health and Human Services. Treatment Methods for Kidney FailureHemodialysis. http://kidney.niddk.nih.gov/KUDiseases/pubs/hemodialysis/index.aspx. Published December 2006. Revised December 21, 2011. Accessed November 30, 2013. 4. US Department of Health and Human Services. Treatment Methods for Kidney FailurePeritoneal Dialysis. http://kidney.niddk.nih.gov/KUDiseases/pubs/peritoneal/index.aspx. Published May 2006. Revised September 2, 2010. Accessed November 30, 2013. 5. Wuerth DB, Finkelstein SH, Schwetz O, Carey H, Kliger AS, Finkelstein FO. Patients' descriptions of specific factors leading to modality selection of chronic peritoneal dialysis or hemodialysis. Perit Dial Int. 2002;22(2):184-90. http://www.ncbi.nlm.nih.gov/pubmed/22098661. Accessed November 29, 2013. 6. Theofilou P. Quality of life in patients undergoing hemodialysis or peritoneal dialysis treatment. J Clin Med Res. 2011;3(3):132-8.
http://www.jocmr.org/index.php/JOCMR/article/view/552/325. Accessed November 29, 2013.

7. Orhan F, Ozer A, Sayarlioglu H, et al. Temperament and Character Profiles of Hemodialysis and Peritoneal Dialysis Patients. BCP. 2011;:1-.

http://www.psikofarmakoloji.org/pdf/21_3_5.pdf. Accessed November 29,2013.

8. Lopes AA, Bragg-gresham JL, Elder SJ, et al. Independent and joint associations of nutritional status indicators with mortality risk among chronic hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). J Ren Nutr. 2010;20(4):224-34. 9. Lopes AA, Elder SJ, Ginsberg N, et al. Lack of appetite in haemodialysis patients--associations with patient characteristics, indicators of nutritional status and outcomes in the international DOPPS. Nephrol Dial Transplant. 2007;22(12):3538-46. http://ndt.oxfordjournals.org/content/22/12/3538.full.pdf+html. Accessed November 29, 2013. 10. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis. 2006;48:S1-S322. http://www.kidney.org/professionals/kdoqi/pdf/12-50-0210_JAG_DCP_GuidelinesHD_Oct06_SectionA_ofC.pdf. Updated 2006. Accessed November 29, 2013.

11. National Kidney Foundaton. K/DOQI Clinical Practice Guidelines for Nutrition in Chronic Renal Failure. Am J Kidney Dis. 2000;35(6):s1-s104. http://www.kidney.org/professionals/kdoqi/guidelines_updates/nut_a15.html. Accessed November 29,2013. 12. Agarwal R, Weir MR. Dry-weight: a concept revisited in an effort to avoid medicationdirected approaches for blood pressure control in hemodialysis patients. Clin J Am Soc Nephrol. 2010;5(7):1255-60.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2893058/. Accessed November 30, 2013. 13. United States Department of Agriculture. USDA National Nutrient Database for Standard Reference. Release 26. http://www.ars.usda.gov/Services/docs.htm?docid=8964. Modified November 25, 2013. Accessed November 30, 2013. 14. Information About the Current Strain of Cloitridium Difficile. Centers for Disease Control and Prevention. Web site. http://www.cdc.gov/HAI/organisms/cdiff/Cdiff-current-strain.html. Last reviewed November 25, 2010. Updated January 25, 2011. Accessed November 29, 2013. 15. Combe C, McCullough KP, Asano Y, Ginsberg N, Maroni BJ, Pifer TB. Kidney Disease Outcomes Quality Initiative (K/DOQI) and the Dialysis Outcomes and Practice Patterns Study (DOPPS): Nutrition guidelines, indicators, and practices. American Journal of Kidney Diseases. 44(5C):39-46. http://download.journals.elsevierhealth.com/pdfs/journals/02726386/PIIS0272638604011047.pdf. Accessed November 20, 2013. 16. Potassium. Lab Tests Online. Web Site. http://labtestsonline.org/understanding/analytes/potassium/tab/glance/. Revised October 15, 2013. Accessed November 29, 2013. 17. PTH. Lab Tests Online. Web Site. http://labtestsonline.org/understanding/analytes/pth/tab/test/. Revised November 15, 2013. Accessed November 29, 2013.
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