MAJOR CASE STUDY: ESRD

MEMORIAL MEDICAL CENTER

KRISTON LOVE
 GENERAL • JF 60 YO Caucasian male
INFORMATI • 6 ft

ON • Admit wt 97 kg
• BMI 30.6 kg/m^2
• Husband
• Admitted 11/24
• Attending Physician
• Robert L Robinson MD
• 2ICU
 PAST MEDICAL HISTORY
• Disease and/or condition
• Former smoker
• HTN
• ESRD s/p kidney-pancreas transplant 2014
• T1DM
• Pulmonary histoplasmosis (SC Pulmonary)

• Hospitalizations
• Current related to histoplasmosis
• Past- ESRD, transplants
• Treatments
• HD prior to transplants
• Medications
• Insulin Pump
• Prednisone
• MagOx
 PRESENT ADMISSION
• Diagnosis/Problem • Significant Lab finding
• Elevated BG 95-273 mg/dL during time of admission
• Pt admitted with complaints of SOB • Mg 1.7 (low)
and fever. Diagnosed with • BUN 26 (high)
pneumonia, sepsis, and hypoxia • Alb 2.9 (low)
• Ca 8.3 (low)
• Physical Examination
• Symptoms
• No physical signs of malnutrition • SOB
• Fever
• NFPE
• Uncontrolled T1DM
• No muscle wasting • RD consulted for ICU vented pt. and to manage
• No fat loss TF

• CBW close to UBW • Other Consults

• Nephrology
• No weight loss documented • Endocrine
 STUDY OF DISEASE: ESRD SECONDARY TO
T1DM
• What is End Stage Renal Disease?
• When kidneys lose their function to filter out wastes and excess fluids from the blood causing
dangerous levels of fluid, electrolytes, and waste to build up in the body.

• Etiology and Occurrence

• Poorly controlled T1DM causes damage to the blood vessel clusters in the kidneys that filter
waste from the blood. This can cause high BP further damaging the kidneys by increasing the
pressure in the filtering system.
• Risk factors that can cause ESRD
• Diabetes with poor blood sugar control
• HTN
• Male sex
• Polycystic kidney disease
• African American descent
• Tobacco Use
• 30% T1DM will develop ESRD vs 10-40% T2DM
 • Incidence of End Stage Renal Disease
• Looked at pts with T1DM and their risks of
developing ESRD

RESEARC • Found that chances of ESRD increase as

the years after diagnosis increases
H ARTICLE • 2.2% after 20 year from diagnosis
• 7% after 30 year from diagnosis
• The younger you are when diagnosed
the lower the risk of ESRD
SYMPTOMS

• N/V • Muscle twitches and cramps

• Loss of appetite • Swelling in feet and ankles
• sleep problems • Chest pain and SOB (fluid
build up)
• changes urination
• HTN
• Decreased mental
• Protein in urine
status
• Labs
• High BUN and Cr in blood
• GFR <15
• Diagnosis
• Blood tests
• Urine tests
• Ultrasound, Magnetic Imaging, CT Scan
• Kidney biopsy
• Medical Treatment
• Peritoneal Dialysis or Hemodialysis
• Kidney transplant
• Kidney-pancreas transplant
• Medical Nutrition Therapy
• Low sodium (300mg or less each serving)
• Low K (3500mg/day)
• Low Phosphorus (1000mg/day)
• Watch fluid intake
• Limit protein intake if not on dialysis
• 0.6-0.8g/kg
• 1.2 g/kg if HD
• 1.2-1.3g/kg PD
• Control BG levels
 Complications and Prognosis
related diseases
Anemia Untreated: Poor.
Bone disease and high phosphorus Dialysis: 20-25% after 1 year, 35%
Heart Disease (CVD) remain alive after 5 years of treatment
High Potassium Transplant: 5 year survival rate is over
80% ; 3% mortality rate after 5 years
Fluid Build-Up
MEDICAL
TREATMENT
• Medications
• While intubated:
• Fentanyl PRN, KCl PRN, D10, LR,
NS and Insulin drip, Propofol
• After Extubation:
• Insulin PRN, 6L O2, Fentanyl
(weaned), D10, Steroid, Abx
• Medical and Surgical Measures
• Ventilator (protect airway)
• Gastric tube (TF while ventilated)
• Chest CT scan
• Bronchoscopy
• General progress
• Extubated after 6 days of being on vent, still had some trouble breathing so on O2
• NPO Clear Liquids CHO Consistent 70gm
• Sepsis resolved, still on Abx for pneumonia which caused acute hypoxic respiratory
failure. Started on steroid. Elevated BG levels (Endo consulted, Carb count)
• Insulin PRN
• Review of MD Progress Summary
• Intubated for acute hypoxic respiratory failure and glycemic control. Underwent
bronchoscopy and had cultures taken (pneumonia)
• Extubated once pain improved and put on O2, continued Abx and downgraded to IMC
• Significantly improved after extubation put on 70 gm diet and cont’d on infection
meds and given Lasix
• BG increased d/t steroid dose increase so insulin PRN (Diabetes following)
• Breathing and appetite improved but still need for O2
• Discharged to inpatient rehab
 MEDICAL NUTRITION THERAPY
• Nutrition Assessment Summary
• 11/24 -Day of Admission. Intubated.
• 11/26
• Intubated. MD started TF of Jevity 1.5 @ 20 mL/hr
• RD to manage. Advanced to goal rate of 50 mL/hr with consideration of Propofol running. + 2 pk BP TID
• 11/29
• Tolerating TF. Continued at goal rate.
• 12/3
• Extubated and advanced to CHO consistent diet (70gm) and encouraged to have 3 HP Ensures/day per
diabetes consultation.
• Pt states appetite is not very good. Reported eating PBJ, soup, and bowl of cereal day before. Ordered cereal,
milk and cheese Danish for breakfast. Reports having nausea. Reports 100 kg UBW. Last BM 11/30.
• NPFE showed no signs of malnutrition
• 12/4
• CHO count ordered
• 12/5
• Pt states appetite is better today, no nausea. Reported sausage gravy on toast and a chocolate Ensure. Pt
reports feeling much better. BG levels still elevated. Ate 100% last 5 meals. Last BM 12/5.
 MNT CONT’D
• Diet Order
• 11/24-11/30
• NPO, started on TF 11/26
• Jevity 1.5 @ 20 mL/hr
• Advanced to goal of 50 mL/hr + 2 pkts BP
• 11/30- discharge
• CHO consistent 70 gm
• Nutrition Care Plan and Recommendations
• Continue with TF until extubated. NPO pending swallow test.
• After swallow test, CHO consistent diet with supplements if needed.
• Patient was very receptive and was compliant
• No education for discharge d/t pt being discharged before next follow up
MNT CONT’D
• Estimated needs:
• 11/26 -11/29 intubated
• 2160 kcal (Penn State), 108-118 gm Pro (1.1-1.2gm/kg ~20% est kcal)
• 12/3- 12/5 Extubation
• 2241 kcal (Mifflin-St. Jeor 1.25 AF), 112 gm Pro (20% est kcal)

• PES Statement and Diagnosis

• Inadequate oral intake (NI 2.1) related to pulmonary histoplasmosis as
evidenced by NPO diet order d/t intubation.
• Pt at risk for malnutrition as evidenced by vent-will continue to monitor
 Medical
Discharged to inpatient rehab
Compliance to Follow Up Plans
Nutrition Care Plan
Patient compliant once appetite was Discharged to inpatient rehab while
getting better following.
Ordered Chocolate Ensures with No plans to follow up after
meals as suggested discharge.
PROGNOSIS
WHAT WOULD I HAVE DONE
DIFFERENTLY?

Background
Ask Provide
Info
More Ask questions Provide DM
background on related to T1DM education if
diet history history non-compliant
• At home diet • Compliance to
habits CHO counting
QUESTIONS?
 • Mayo Clinic
• https://www.mayoclinic.org/diseases-conditio
ns/end-stage-renal-disease/symptoms-cause
s/syc-20354532
• American Family Physician
• https://www.aafp.org/afp/2010/1215/p1512.
RESOURC html
• Nutrition Care Manual
ES • Incidence of End Stage Renal Disease in Patients
with Type 1 Diabetes
• Helve, J., Sund, R., Arffman, M., Harjutsalo, V., Groop, P.-
H., Grönhagen-Riska, C., & Finne, P. (2018). Incidence of
End-Stage Renal Disease in Patients With Type 1
Diabetes. Diabetes Care, 41(3), 434–439. https://doi-
org.libproxy.lib.ilstu.edu/10.2337/dc17-2364

• University of California San Francisco

• https://pharm.ucsf.edu/kidney/need/statistic
s