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Major Case Study Theresa Price The University of Southern Mississippi

MAJOR CASE STUDY Table of Contents I. Introduction: Patient Information II. Literature Review III. Nutritional Treatment IV. Assessment V. Diagnosis VI. Intervention VII. Monitor and Evaluation VIII. Conclusion IX. Appendices X. References

3-4 4-8 8-9 9-10 11 11 12 12-13 14-18 19-24

MAJOR CASE STUDY Introduction: Patient Information CR was a 51 year old, black female admitted to Hattiesburg Clinic Dialysis Unit on March 3, 2007. She was recently admitted to Forrest General on February 21, 2013 to February 23, 2013. She drove herself to the hospital due to heart palpitations. She presented with complaints of chest pain. CR weighed 153 pounds and was 61 inches tall. Her ideal body weight was 105 pounds; therefore, her current weight was 145% of her ideal body weight. Her

adjusted body weight was calculated to be 117 pounds. CR was diagnosed with atrial fibrillation during the hospitalization stay. Common treatment approaches for atrial fibrillation is to treat the underlying disorders, medication use, or procedures to control heart rhythm. CR has a family history of kidney issues, such as father and brother both having kidney disease and kidney failure. CR developed kidney disease due to uncontrolled hypertension and has been receiving hemodialysis since March 3, 2007. Common treatment options for End Stage Renal Disease (ESRD) are hemodialysis, peritoneal dialysis, or transplant. CR has a kidney transplant referral on hold due to current heart conditions. Nelms, Sucher, and Long (2007) provide details on the three different treatment options for ESRD. Dialysis is a manual procedure that removes excess toxins, wastes, and fluids from the blood when they kidneys are no longer able to filter properly. Hemodialysis operates from a machine and has a selective membrane in which the excess is pulled out of the blood by osmosis into the man made dialysates. Hemodialysis has a permanent access site usually in the patients arm. Patients who have hemodialysis performed spend three to five hours, three times a week in a renal unit for this procedure. Peritoneal dialysis goes into the patients peritoneal wall of the abdomen region and serves as the selective membrane to pull excess from the blood. Patients are trained to perform peritoneal dialysis manually if the machine were to stop working, but generally this procedure


can be done at home and overnight. Transplantation is the preferred method of treatment but is a difficult procedure that requires perfect matching of tissue types as well as determining the health status of the patient. A surgeon places the new kidney inside the lower abdomen and is connected to the artery and vein in the pelvis (Medline Plus, 2011). After transplantation there are immunosuppressive actions to reduce rejection (Nelms, Sucher, & Long, 2007). CR also has a past medical history of Hypertension, Coronary Artery Disease, and Congestive Heart Failure. Literature Review Primary Diagnosis: Hypertensive Kidney Disease with End Stage Renal Disease The kidneys are an important organ in the body that filters waste and excess fluid from the blood (National Kidney Foundation, 2014). The American Kidney Fund Organization defines End Stage Renal Disease (ESRD) as when the kidneys do not work as efficiently as to perform the necessary functions to sustain life without dialysis. ESRD is generally caused by uncontrolled diabetes or hypertension (American Kidney Fund, 2014). When a person is considered to have ESRD they have lost at least 90% of total kidney function (National Kidney Foundation, 2014). When hypertension is uncontrolled the blood pressure damages blood vessels in the body and the nephrons in the kidneys, which results in decreased function from the kidneys as they are unable to remove wastes and fluids from the blood. The decreased kidney function can further raise blood pressure (National Kidney Foundation, 2010). Uncontrolled diabetes also damages the blood vessels due to high levels of insulin circulation, and the kidneys reduce the ability to filter the blood and may cause edema and proteinuria. Diabetes can also damage nerves in the body, which can reduce bladder emptying, resulting in holding urine for long periods of time, causing infections (National Kidney Foundation, 2014).

MAJOR CASE STUDY The National Kidney and Urologic Diseases Information Clearinghouse (2012) reported that one out of every 10 Americans, more than 20 million, have chronic kidney disease and adults over 65 years of age have a higher incidence of this disease. In 2009 over 350 million people were known to have ESRD, 871,000 people were being treated for ESRD, and 172,000 people have received a transplant. This disease is associated three times higher for African Americans than Caucasians. There are many different symptoms that may be unnoticed. Some of the symptoms reported in a research review conducted by Murtagh, Addington-Hall, and Higginson (2007) included fatigue, pruritus, constipation, anorexia, pain, sleep disturbance, anxiety, dyspnea, nausea, restless legs, and depression. Other symptoms noted from Medline Plus (2012) may include nail changes, bone pain, confusion, easy bruising, amenorrhea, and edema.

ESRD is treated by hemodialysis, peritoneal dialysis, or kidney transplant. The prognosis for ESRD is guarded. If the patient does not receive dialysis or transplant they will die, but the outcomes with treatment reduces mortality rates. ESRD is irreversible and the person can never regain kidney function once it is lost (Medline Plus, 2011). Secondary Diagnosis: Hypertension, Atrial Fibrillation, Coronary Artery Disease, and Congestive Heart Failure. CR has a history of Hypertension (HTN), which relates to her current primary and other secondary diagnoses. Carretero and Oparil (2000) state that essential HTN is a risk factor for cardiovascular disease, heart failure, and ESRD. Many patients who are on hemodialysis have HTN, which suggests a risk factor for cardiovascular mortality (Horl, 2010). At least 75 million Americans have HTN and are on medication for this disorder, and out of this population, African Americans have the highest risk (Madhur et al., 2014). The risk factors for developing HTN

MAJOR CASE STUDY including obesity, insulin resistance, high alcohol intake, high salt intake, aging, sedentary

lifestyle, stress, and low potassium and calcium intake. When blood pressure is uncontrolled and becomes high it damages nephrons and arteries, while narrowing blood vessels throughout the body, which can affect the kidneys, heart, brain, eyes, and limbs (Blood Pressure Association, 2008). HTN is relatively asymptomatic, if a person experiences an extremely high blood pressure it may be a hypertensive crisis and may experience severe headache, severe anxiety, shortness of breath, or nosebleed (American Heart Association, 2012). HTN can be controlled with blood pressure medications and lifestyles changes such as weight loss, reduced alcohol intake, reduced sodium intake, smoking cessation, adequate potassium and calcium intakes, and regular exercise. If HTN has caused ESRD or heart failure the prognosis is poor since these are irreversible, but if blood pressure is controlled before irreversible damages then the prognosis may be better (Blood Pressure Association, 2008). CR suffered from atrial fibrillation (AF) and was admitted to the hospital, which may be related to her ESRD and history of heart failure. CR had a high potassium level of 5.7mg/dL at the same time as being admitted for AF. High potassium levels can cause irregular heartbeat (Davita, 2014). When the electrical signals in the heart travel in a less than sufficient way and become rapid, AF is diagnosed. Damage of this sort can be caused by high blood pressure (Falk, 1998; National Heart, Lung, and Blood Institute, 2011). Having a history of heart failure can also contribute to AF (Ng, Edwards, Lip, Townend, & Ferro, 2013). If a patient has cardiomyopathy and coronary artery disease they are likely to experience AF (Falk, 1998). AF is a concern because many studies have shown increased mortality in patients on dialysis (Ng, Edwards, Lip, Townend, & Ferro, 2013). AF can occur for different reasons but one may be due to atrial enlargement and stretch (Janse, 1997). AF is typically associated with a variety of cardiac

MAJOR CASE STUDY disorders and may not present symptoms (Falk, 1998). AF symptoms defined by the National Heart, Lung, and Blood Institute (2011) include palpitations, shortness of breath, chest pain, fainting, fatigue, or confusion. There are currently between 2.3 million and 5.1 million

Americans who are affected with this disorder (Harvard Health Publication, 2011). Patients who gain control of the underlying treatments have a positive prognosis. Treatments of AF include treatment of the underlying condition, medications, and pumping the heart manually to regain natural rhythm (National Heart, Lung, and Blood Institute, 2011; Thihalolipavan & Morin, 2014). Coronary Artery Disease (CAD) begins with damage to the coronary artery. The damage can be caused by smoking, high blood pressure, high cholesterol, and diabetes (Mayo Clinic, 2012). When the arteries contain too much plaque and narrow they lose ability to supply oxygen to the heart causing symptoms such as chest pain, shortness of breath, or heart attack (Centers for Disease Control and Prevention, 2013). This type of heart disease is the most common among Americans and is the current leading cause of death (Lala & Desai, 2014; National Heart, Lung, and Blood Institute, 2012). CAD is common in patients who have ESRD. Patients who have CAD and ESRD generally have poor cardiac outcomes (Hedayati & Szczech, 2004). CAD narrows the blood vessels that supply the oxygen to the heart and can weaken the muscle (Medline Plus, 2013). A risk factor for individuals with CAD and ESRD is vitamin D status. Recent research conducted by Chen et al. (2014) concluded that low vitamin D is associated with CAD severity. Since milk and other dairy products are high in phosphorus, these products are recommended for consumption in low amounts for kidney failure patients (National Kidney Foundation, 2014). Persons with ESRD and CAD increases their chance of death by 50%, and the risk of a 30-year-old ESRD patient developing CAD is similarly calculated to the risk of a 70

MAJOR CASE STUDY or 80 year old without renal disease. Patients with inflammation and oxidative stress due to ESRD also have abnormal vasodilatation and increased extravascular resistance, which contributes to Cardiovascular Disease (CVD) in ESRD. Renal insufficiency has been shown to increase the atherosclerotic process (Stenvinkel, Pecoits-Filho, and Lindholm, 2003).

CR also has a diagnosis of Congestive Heart Failure (CHF). According to the Centers for Disease Control and Prevention, nearly 5.1 million Americans have heart failure (Centers for Disease Control and Prevention, 2013). CHF is defined as a condition where the heart cannot efficiently pump enough oxygenated blood throughout the body (Medline Plus, 2013). CHF occurs after a long period of time and is caused by CAD and uncontrolled HTN. Heart failure is present when the heart is not able to efficiently pump blood out of the heart normally and when the muscles become stiff and do not fill up with blood effectively. Since CHF is a chronic condition and develops over time the symptoms may not seem urget. Common symptoms include cough, fatigue, loss of appetite, nocturia, irregular pulse, shortness of breath, swollen feet and ankles, and breathing issues. CHF has a poor prognosis but can be managed by medications and lifestyle factors such as reducing alcohol intake, smoking cessation, regular exercise, weight loss, low cholesterol, and adequate rest (Medline Plus, 2013). Nutritional Treatment Nutritional treatment for a patient with ESRD is highly individualized. There are different stages of kidney disease and once a person reaches ESRD they must start either hemodialysis or peritoneal dialysis, unless they are receiving a kidney transplant. Each form of treatment requires a different type of nutritional management. CR was receiving hemodialysis, her nutritional needs for this diagnosis include 1.2 grams per kilogram of body weight for protein with at least 50% from high biological value, 30 to 35 calories per kilogram of body weight, 20

MAJOR CASE STUDY to 25% from total fat, less than 200 milligrams a day of cholesterol, 20 to 30 grams a day of fiber, two to three grams a day of potassium, two to three grams a day of sodium, one liter of fluid a day, no more than 2,000 milligrams a day of calcium, and 800 to 1,000 milligrams a day

of phosphorus (Nelms, Suchar, & Long, 2007). The Evidence Analysis Library (EAL) states that hypertension and hyperlipidemia are higher in chronic kidney disease patients and serum potassium levels should be monitored closely because of the effects of certain antihypertensive medications on potassium excretion (EAL, 2007). CR had other co-morbidities that were considered when calculating her nutritional needs such as HTN, CAD, CHF, and atrial fibrillation. HTN nutritional needs are typically treated with a diet of 27% fat, 6% saturated fat, 18% protein, 55% carbohydrates, 150 milligrams of cholesterol, 2,300 milligrams sodium, 4,700 milligrams potassium, 1,250 milligrams calcium, 500 milligrams magnesium, and 30 grams of fiber (National Heart, Lung, and Blood Institute, 2012). For heart failure it is recommended to consume 2,000 milligram of sodium, fluid should limited 1,500 to 2,000 milliters a day (Nelms, Suchar, & Long, 2007). The EAL (2009) states that adults with cardiovascular disease who consume fish with omega-3 fatty acids weekly provides a protective effect from cardiovascular events such as reducing the risk of arrhythmias and fatal heart conditions. With this statement it can be useful to recommend fish high in omega3 fatty acids to CR. Assessment Anthropometric Measures CR weighed 153 pounds, estimated dry weight (EDW) is 152 pounds, and she is 61 inches tall, making her BMI 28.7, which is classified as overweight. Her ideal body weight was

MAJOR CASE STUDY 105 pounds and her adjusted body weight was 117 pounds. She also had an average intradialytic weight gain of four pounds and no present edema during assessment. Medications CRs medications were mainly related to ESRD. A detailed list of the medications and the reason for use are listed in Appendix A. Laboratory Values CRs recent laboratory values both within normal limits and explanations for abnormal values can be found in Appendix B. The recent values and explanations for fluctuations of Parathyroid Hormone (PTH), Cholesterol, and Potassium can be found in Appendix C. Diet Order and Nutrient Needs


CR was ordered a Renal Select diet and her needs were calculated using 30 to 35 calories per kilogram of EDW. Her calorie needs were equal to 2070 to 2415 calories per day. Her protein needs were calculated using 1.2 grams were kilogram of EDW and were equal to 83 grams of protein per day. Patients on dialysis have increased risks of malnourishment and loss of amino acids with each dialysis treatment; therefore, increasing the patients energy and protein needs. Diets lower than 1.2 grams of protein per kilogram of body weight yielded a negative nitrogen balance, providing that the recommendation for protein should be 1.2 grams per kilogram of body weight or higher (Wolfson, 1999). CRs fluid needs were set at 1,200 milliliters per day due to the renal diet. Fluid is restricted to about 1,200 milliliters per day because too much fluid can cause discomfort for patients on hemodialysis such as swelling, shortness of breath, muscle cramping, and drops in blood pressure (Davita, 2014). Within the dialysis clinic the Renal Select diet consists of 2340 milligrams a day of Potassium (K), 2530 milligrams of Sodium (Na) a day, and restricted Phosphorus (P) intake. A functioning kidney



excretes excess K, Na, and P but a person with ESRD is unable to filter these waste products and can have severe consequences if the intakes of the nutrients are not monitored. High levels of K can increase risks for heart issues and muscle cramps, high levels of P can cause complications with the heart as well as cause brittle bones (Davita, 2014). High levels of Na can increase heart complications, shortness of breath, and edema (Davita, 2014). Upon assessment, CR reported a very good appetite and intake level. The patients reported 24-hour recall and nutrient analysis can be found in Appendix D. Her estimated intake was approximately 1791 calories and 62 grams of protein, which both fall well below the calculated estimated needs. CRs K, Na, and P intake was approximately 1831 milligrams, 2434 milligrams, and 813 milligrams, respectively, which were below the restricted limits. Diagnosis Excessive potassium intake RT physiological causes decreasing nutrient needs due to chronic renal disease AEB Potassium level of 5.1mg/dL and heart palpitations. Predicted excessive nutrient intake of Vitamin D (Zemplar) RT recent high dosage due to very high PTH values and needed Vitamin D to decrease levels AEB a large reduction in PTH values since labs last taken. Intervention The intervention for this patient included an education session on high and low K foods. The patient was provided a handout with high and low K foods, as well as a dialysis friendly grocery list and cook book. The Zemplar was also discontinued as an intervention to stop reducing the PTH levels.

MAJOR CASE STUDY Monitoring and Evaluation Monitor monthly labs of K to determine diet compliance, and monitor PTH every four months, and Cholesterol year every to determine compliance with diet and medication. Goals for CR


include K, PTH, and Cholesterol being within normal limits and having a better understanding of high and low K foods. Conclusion The EAL (2001) concluded that Registered Dietitians (RD) who provide Medical Nutrition Therapy (MNT) to patients with chronic kidney disease is more effective on nutritional status that patients who do not receive MNT by a RD. Approximately two hours a month for 12 months can improve anthropometric and biochemical measures among patients with chronic kidney disease. CR has been on hemodialysis Monday, Wednesday, and Friday, for three to five hours since 2007 and appeared to be very compliant for the majority of laboratory values. She was also very willing to discuss lab values, nutrition handouts, and ways to improve her lab values. She generally has good control of her nutritional status. Her prognosis at this time is guarded due to ESRD, if her current heart conditions do not continue to progress over time she may become eligible for the kidney transplant again, which could positively impact her prognosis. CRs PTH value (44.5) was low at the December drawing due to having both Sensipar and Zemplar prescribed at the same time, which were to reduce the high PTH value (600) at the drawing in September. The Zemplar was discontinued to allow PTH values to rise, which were indicated in the April lab results (399). The April lab resulted in a PTH value rose above the normal limits, and the treatment options were to reinitiate the vitamin D at a lower dose in addition to the Sensipar, which could increase calcium levels to an unsafe level, or to increase the Sensipar, which could potentially decrease calcium to an unsafe level. After

MAJOR CASE STUDY medications were increased, the calcium levels would need to be checked in one week and the


PTH levels would need to be rechecked in one month to determine proper dosage. In November and December CR had poor dietary intake, which reflected in her November lab for albumin (3.2g/L) and her December lab for low Cholesterol (122mg/dL). The cholesterol screening is drawn once a year, if CRs intake continues to be good then the cholesterol should increase at the next lab screening. CR had a slightly high K value for March labs (5.1mEq/L), which had decreased since February (5.7 mEq/L). The diet education consisted of a low potassium intake with an emphasis on shopping and cooking for foods that are allowed on the Renal Select diet.

MAJOR CASE STUDY Appendix A: Table 1: Medications Medication Sensipar Metoprolol Justification



Coumadin Epoeitin Alfa


Gabapentin *Information cited from Pronsky (2008).

Antihypercalcemia drug that reduces PTH and also reduces calcium levels Antihypertensive drug, Beta Blocker, lowers blood pressure, used to treat CHF and other heart conditions Phosphate binder, main use is to reduce phosphorus level. It can also reduce LDL cholesterol, total cholesterol, and PTH levels and increase calcium levels. Anticoagulant drug that makes the blood thinner, is used for atrial fibrillation Recombinant Human Erythropoietin drug used to stimulate RBC production since kidneys can not do this function anymore. Antiulcer and Antigerd drug used to treat GERD. Proton Pump Inhibitors decreased gastric acid secretion. Anticonvulsant drug, used to treat neurologic disorders.

MAJOR CASE STUDY Appendix B: Table 2: Laboratory Values at Assessment Lab Measure Urea Reduction Ratio Kt/V Calcium Phosphorus Ca:Phos Product Parathyroid HormoneIntact Patient Value 78.85% 1.86 9.0mg 4.2mg/dL 38mg/dL 44.5 Normal Renal Value >65% >1.5 8.5-9.5mg/dL 3.5-5.5mg/dL <55mg/dL 150-300


HbA1c Cholesterol

n/a 122mg/dL

<7.0% 140-199mg/dL

LDL-Cholesterol HDL-Cholesterol Triglyceride Albumin-Green Potassium`

55mg/dL 47mg/dL 98mg/dL 4.2g/L 5.1mEq/L

<100mg/dL 41-75mg/dL 35-159mg/dL >4.0g/L 3.5-5.0mEq/L

Magnesium 2.2mg/dL *Information cited from Owens (2014).


Reason for Abnormality Normal Normal Normal Normal Normal Low due to medications. Previously the patients last PTH was over 600. She was placed on Vitamin D and Sensipar to reduce the level. Has since been discontinued with Vitamin D. n/a Lab was pulled in December, low due to poor diet in recent months of November and December. Appetite has increased and this value is expected to increase at next draw. Normal Normal Normal Normal Slightly high due to intake of high K foods. Patient has decreased significantly since last months labs were pulled (5.7mEq/L) Normal

MAJOR CASE STUDY Appendix C: Laboratory Fluctuations (PTH, Chol, Albumin, and K)
PTH Lab Value






Chol Lab Value


K Lab Value


MAJOR CASE STUDY Appendix D: Reported 24 hour Recall Breakfast Coffee (8oz) Oatmeal w/Raisins (1 instant packet w/ oz) 2 Toast w/ Butter (White w/ 1 tbsp) Lunch Grilled Chicken (Med. Breast) Salad: Lettuce, Tomatoe, Cucumber, Onions, Carrots (2 c total) Ranch Dressing (3 tbsp) Snack Peanut Butter Crackers (6) Apple Pie (1/8th of the pie)


Dinner Wendys Plain Burger (2 buns, 1 patty) Doritos (1.5oz)

Nutrient Analysis of 24 hour Recall Nutrient Total calories Protein CHO Fiber Total Fat Sat fat Chol Ca K Na Iron Mg P Zinc Vitamin A Vitamin B12 Vitamin C Vitamin D Vitamin E Folate Niacin Riboflavin Thiamin Vitamin B6 Amount 1791kcal 62g 14%, 207g 17g 41%, 82g 12%, 24g 137mg 467mg 1831mg 2434mg 17mg 220mg 813mg 6mg 1067 RAE 1.5 mcg 36mg 0mcg 8mg 439 mcg 24mg 1.1mg 1.1mg 1.4mg



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