OBJECTIVES

➢ Understand what caused CKD for this patient.

➢ Understand the development of psychogenic polydipsia.

➢ Know the reasoning behind each nutritional diagnosis.

➢ Understand the prognosis.

BACKGROUND
• GG is 58 years old, admitted to DSH-P August 2, 1996.
• Diagnosed with schizoaffective disorder bipolar type at age 17.
• Prior to admission he was living at a group home.
• GG stays in contact with his mother who calls frequently.
• Current medical conditions of interest:
• HTN (1998)
• Anemia (2008)
• Edentulous
• Chronic mild hyperkalemia (2008)
• Hyponatremia/polydipsia (2008)
• Thrombocytopenia
• Chronic kidney disease/hydronephrosis (2008)
• B/L Pedal edema
• Urinary retention
FOCUS OF STUDY
1. Chronic Kidney Disease (CKD)
• Epidemiology: 1 in 10 people in the U.S.
• Etiology: Diabetes, HTN, Glomerulonephritis
• S/S: edema, metabolic acidosis, anemia, uremia, hyperphosphatemia,
HTN, hyperkalemia.
2. Hyponatremia/Polydipsia
• Epidemiology: 20% of all psychiatric patients
• Etiology: Sodium levels drop below 135 mmol/L
• S/S: occur when serum sodium is < 120 mmol/L- seizures, drowsiness,
irritability, vomiting, confusion, twitching, muscular weakness,
behavioral changes, and headaches.

Nelms et al. (2015)

McCauley & Gill (2014)
CKD (Etiology)
● GG has history of HTN and currently has a open focus 6 from 1998
○ HTN is likely idiopathic, however, water intoxication causes hypervolemia,
worsening blood pressure.

● Blood pressure is largely regulated by sodium and chloride, as kidney function

declines sodium retention and edema occurs.

McMahon et al. (2012)

CKD (Hyperkalemia)
● Hyperkalemia- Potassium level > 5.5 mg/dL
● S/S- N/V, Feeling of numbness or tingling, Palpitations, Chest pain
● When kidneys are functioning adequately they excrete 80%-90% of potassium
consumed.

● Potassium restriction indicated < 2000 mg/day

● Safe zone= 3.5-5 mEq/dL
● Caution zone= 5.1-6 mEq/dL
● Danger zone= > 6 mEq/dL

https://www.kidney.org/atoz/content/potassium
CKD (Metabolites)

● Elevated BUN- As CKD continues to progress the ability to excrete

nitrogenous waste declines and blood urea and other compounds
increase, resulting in azotemia.
● Elevated Creatinine- A waste product in your blood that comes from
muscle activity. Normally removed from the blood by the kidneys. As
kidney function declines creatinine levels rise.

https://www.kidney.org
CKD (Anemia)
● Hemoglobin- Normal range= 13-17.5 g/dL
● Hematocrit- Normal range= 42-52%
● Etiology in CKD- Microcytic anemia is common in CKD because the
kidney is no longer able to produce the hormone erythropoietin, which
stimulates the production of red blood cells.
● Symptoms- Lethargy
● Treatment- Iron supplements and hormone erythropoietin.
● Goal for treatment-
○ Hemoglobin= >11 g/dL
○ Hematocrit= >33 %

https://www.kidney.org
Hyponatremia
Etiology Hyponatremia-
● Diuretic use
● Diarrhea
● Heart failure
● Liver disease
● Renal disease
● Syndrome of inappropriate ADH secretion (SIADH)
● Patient is drinking greater than 10 liters/day of water.
● Maximum dilution of urine is reached 100 mOsm/kg.
● Antidiuretic hormone is fully suppressed.

Nagasawa et al. (2014)

Psychogenic Polydipsia
Etiology Psychogenic polydipsia-
● Osmotic set point for Arginine vasopressin could be lower, causing
impairment in water excretion.
● High dopamine levels may affect thirst.
● Drinking to counteract side effects of psychotropic medications.
● Alterations in feedback to the hypothalamic-pituitary axis.

Nagasawa et al. (2014)

Case study
● Water intoxication has no established diagnostic criteria but is best
diagnosed by observation of behavior.
○ Behavior to watch for would be constant trips to the restroom and
patient constantly drinking fluid.
● Olanzapine in one study was found to possibly aggravate water
intoxication if blood concentration was more than optimal 20-40 ng/mL.
○ Olanzapine used within normal limits (WNL) can be used to treat
water intoxication by reducing the patients sense of anxiety (Bhatia
et al. 2017).

Nagasawa et al. (2014)

CKD 4 nutritional needs recommendations
★ Energy:
○ 25-35 kcal/Kg adjust for wt. gain or loss.
★ Protein:
○ Limiting portion sizes of proteins.
■ 0.6-0.8 g/kg
○ Replace some animal proteins with proteins from plant sources.
■ If plant based protein used watch potassium and phosphorous.
★ Fluids:
○ The kidneys normally remove extra fluid from the body.
○ The Dr. may prescribe medications.
○ If pt. is experiencing oliguria a fluid restriction may be indicated.

Nutrition care manual

CKD 4 macromineral restriction
★ Controlling blood pressure:
○ Watch sodium in diet.
■ Too much may increase thirst and cause retention of fluid.
○ Amount recommended varies from 1-3 grams a day.
★ Phosphorous:
○ Elevated levels may indicate bones are being affected.
○ Lower phosphorus diet indicated.
○ Phosphate binders prescribed if diet intervention fails.
★ Potassium:
○ Potassium restriction is not usually indicated.
○ If potassium levels are high fewer potassium rich foods is
recommended.

Nutrition care manual

Counselling Tips

● Stick to foods and portions offered on your meal plan.

● Try not to skip meals for carbohydrate control.
● Don’t add salt to your food.
○ If your snacking outside of meals choose foods 300 mg of Na
or less.
● If phosphorus binders prescribed take them with meals or as
recommended.
● Avoid eating too many high potassium fruits and vegetables.

Nutrition care manual

First visit-Assessment
12/4/18 Diet Mechanical Soft Advanced (2300-2500 kcal/day) 2gm sodium with snacks.
Note: Mocha mix in place of milk at B/D for mild protein restriction. Pt. receives additional
snacks. Pt. does not receive salt sub.
Reasons for diet:
• Edentulous
• High blood pressure
• Mild protein restriction
• Increased energy needs

Patient has variable intake, and has been on 1:1

MEDICATIONS
Amlodipine Besylate Omeprazole
Docusate sodium Propanolol
Haloperidol Sodium Polystyrene Sulfonate
Hydralazine Tamulosin
Lactulose Tramadol HCL
Lorazepam Zonisamide
Olanzapine Clonidine
KNOWLEDGE/BELIEFS/ATTITUDES

Patient showed minimal knowledge regarding choking prevention, CKD,

and HTN. Patient acknowledges that these conditions are present but was
not able to verbalize understanding. When asked if he knows what CKD and
GFR are pt. stated “Yes I do.”

Contemplation Stage of change.

BEHAVIOR/ PHYSICAL ACTIVITY
Behavior:
Patient was found pacing the day hall and watching the news. Patient accepted
the interview but continued pacing. Patient terminated interview and became
agitated when asked about CKD.

Patient has history of refusing annual H&P, but has agreed to allow dietitian to
change diet as needed.

Physical activity:
Patient is known to pace hallways for long periods throughout the day. Patient is
considered active.
ANTHROPOMETRICS
Height: 70” Weight: 146 lbs. BMI: 21

Waist circumference: 45” Increase weight trend: + 9 lbs. in 3 months.

Pt. weight fluctuates but has remained stable above 140 lbs. for one month.
Water intoxication alarms:
1st alarm 140 lbs.
2nd alarm 144 lbs.
BIOCHEMICAL
(12/3/18)
Na 125 (L)
Patient has remained on 1:1 for water intoxication since last interview by
dietitian.
Sodium levels have trend down since implementation of low sodium diet.

(10/18/18)
BUN 42 (Hi), Creat 2.61 (Hi), GFR 26 (L)

(10/10/18)
BUN 35 (Hi), Creat 2.33 (Hi), Alb 2.8 (L)
Nutrition focused physical findings

● Digestive: Staff reported no GI distress.

● Teeth/Swallowing: Pt. is edentulous

and reports no chewing swallowing
problems. Aspiration Dysphagia Risk
Screen 15/35 for missing teeth and
GERD.

● Cardiovascular: (11/25/18-12/04/18)
173/93 mmHg; poor control
Appropriate weight range/Estimated needs
AWR= 150-182 lbs. Gradual wt. gain is recommended.

Estimated energy needs: 2300-2650 kcal (35-40 kcal/kg)

Estimated protein needs: 55-80 g (0.8-1.2 g/kg)

Estimated fluid needs: 1650-2000 ml (25-30 ml/kg)

Reasoning: GG has struggled to gain wt. in the past and has possible inflammation or
low protein stores.
Diagnosis/Intervention

Dx: Limited adherence to nutrition-related recommendations R/T lack of

value for behavior change and previous lack of success in making health-
related changes AEB failure to engage in meaningful counseling and
expected laboratory outcomes not achieved.
Intervention:
Meals and snacks- Sodium levels have been declining since 2-gram sodium
diet implemented. Mocha mix is supplementing milk to address protein
restriction for CKD.
Goal: Pt. to exhibit improved nutrition outcomes.
Monitoring and evaluation/Recommendations
● Food and nutrient intake:
● Adhere to diet.
● Biochemical Data:
● Pt. will have stable or improved albumin.
● Pt. will have stable or improved sodium levels.
● Nutrition-Focused Physical Findings:
● Pt. will exhibit improved BP control towards goal.

Recommendations:
MD: Change diet to Mechanical Soft Advanced with additional snacks.
Second Visit-Assessment
1/4/19 Diet Mechanical Soft Advanced (2300-2500 kcal/day) with snacks.
Note: Mocha mix in place of milk at B/D for mild protein restriction. Pt. receives
additional snacks. Pt. does not receive salt sub.
Reasons for diet:
• Edentulous
• Mild protein restriction
• Increased energy needs

Patient has variable intake, and is no longer on 1:1

MEDICATIONS: No change
Amlodipine Besylate Omeprazole
Docusate sodium Propanolol
Haloperidol Sodium Polystyrene Sulfonate
Hydralazine Tamulosin
Lactulose Tramadol HCL
Lorazepam Zonisamide
Olanzapine Clonidine

Was given a double dose of: Sodium Polystyrene Sulfonate 12/31/18 for elevated potassium.
KNOWLEDGE/BELIEFS/ATTITUDES

Pt. displayed inadequate knowledge regarding S/S of water intoxication

and hyperkalemia “I don’t know, what are they?” Pt. verbalized awareness
of his kidney function stating “I know I have that” when asked about CKD.
Pt. wants to be off of Mechanical Soft Advanced diet, but was counseled to
agree that this diet is best for him.

Contemplation Stage of change.

Behavior/Physical Activity
Behavior:
Pt. was found pacing the hallways and presented with more awareness
compared to last visit. Pt. was willing to speak with this writer, however gets
inpatient and begins pacing. It is best to focus on the most pressing
problems.

Physical Activity:
Pt. is active, staff reports pt. paces hallway all day.
ANTHROPOMETRICS
Height: 70” Weight: 141 lbs. BMI: 20.3

Waist circumference: 45” Fluctuates weight trend: -5 lbs. (3.42%) x 6 months

Range: 135-148 lbs. x 6 months.
Pt. weight fluctuates due to water intoxication.
Water intoxication alarms:
1st alarm 143 lbs.
2nd alarm 147 lbs.
BIOCHEMICAL
(1/4/19)
Na 138, K 4.9
(12/27/18)
Na 131 (L), K 5.8 (Hi), Gluc 119 (Hi), BUN 46 (Hi), Creat 3.13 (Hi), Alb 2.9 (L), Globulin 4
(Hi)
(12/3/18)
Na 125 (L)
(10/10/18)
BUN 35 (Hi), Creat 2.33 (Hi), Alb 2.8 (L)
(10/18/18)
BUN 42 (Hi), Creat 2.61 (Hi), GFR 26 (L)
NFPE/Estimated needs
There was no improvement in blood pressure since last visit.
Mean for last 10 blood pressures= 169/93 mmHg

Estimated Energy Needs: 2250-2550 kcal (35-40 kcal/kg)

Estimated Protein Needs: 50-75 g (0.8-1.2 g/kg)

Estimated Fluid Needs: 1600-1900 ml (25-30 ml/kg)

Diagnosis/Intervention
Diagnosis:
Inadequate energy intake R/T psychological causes AEB failure to gain wt.,
variable intake, and mental illness.
Intervention:
● Adding additional snacks to promote wt. gain.
○ Pt. now receives Gram Crackers twice a day.
○ Total increase of kcal = 180
Goal:
Maintain or gain wt. x 1 month.
Monitoring and Evaluation

Behavior:

Pt. to report not taking prune juice more than 1 time a day.

Food and nutrient Intake:

Pt. to report eating 100% at meals and provided snacks.

Anthropometrics:

Wt. gain toward AWR.

Quick note: Diet Change
● Labs: 1/16/19
○ Creat. 3.92 mg/dL
○ BUN 67 mg/dL
○ K 5.7 mEq/dL
○ GFR 16 ml/min/1.73m2
● Recommendation: Mechanical Soft
Advanced, 2-3gm potassium, 40-65 gm
protein with snacks
○ Kcal: 2250-2550 (35-40 kcal/kg)
○ Protein: 40-65 g (0.6-1.0g/kg)
○ Fluids: 1600-1900 (25-30 ml/kg)
Conclusion/Prognosis

● Treatment will focus on maintaining

comorbidities.
● GG is most likely to begin dialysis if
renal function continues to decline.
○ Medical probate.

● Psychogenic polydipsia is a condition

that will need continuous treatment.
References
Nelms, M., Sucher K. P., Lacery, K. (2015) Nutrition Therapy and Pathophysiology. Boston, MA: Cengage

Learning

McCauley, M., Gill, M. (2014). Psychogenic Polydipsia: The Result, or Cause of, Deteriorating Psychotic

Symptoms? A case Report of the Consequences of Water Intoxication. Case reports in psychiatry 2015. doi:

10.1135/2015/846459

Nagasawa, S., Yajima, D., Torimitsu, S., Abe, H., Iwase, H. Fatal water intoxication during olanzapine

treatment: A case report. Legal Medicine 16 (2014) 89-91.

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Anemia in Chronic Kidney

Disease. Retrieved from: https://www.niddk.nih.gov/health-information/kidney-disease/anemia

Bhatia., Goyal, A., Saha, R., Doval, N. (2017). Psychogenic Polydipsia-management challenges. Shanghai

Archives of Psychiarty, 29 (3).

McMahon, E., Bauer, J., Hawley, C., Isbel, N., Stowasser, M., Johnson, D., Hale, R., Campbell, K. (2012). The

effect of lowering salt intake on ambulatory blood pressure to reduce cardiovascular risk in chronic kidney disease

(LowSalt CKD study): protocol of a randomized trial. BMC Nephrology 13:137. doi: 10.1186/1471-2369-13-137.

https://www.kidney.org

Nutrition care manual