ERSD: END STAGE RENAL DISEASE
Kathryn AtwaterPVAMU Intern 2012-2013
Patient Background
71 year old Hispanic, white female Middle Class Separated Lives with daughter 3 children History of tobacco use but no alcohol Stage 5 Renal Failure
General Health History Sleeps well Light physical activity
Limited due to walker Housework Tries to “walk” as much as possible
Lost 50 lb over past year Food intake varies based on daughter Alert with some memory loss
Recent Medical History First hospitalized 1/30/13 for:
Chronic CHF exacerbation Anemia
2/3/13 CVC placed in right chest High creatinine finalized decision (5.06
mg/dL) Started hemodialysis immediately
No previous dialysis Plans to get AVF as soon as possible
Past Medical History Diabetes Mellitus Hypertension Congestive Heart
Failure Coronary Artery
Disease Hypercholesterolemi
a Legally Blind Glaucoma
Anemia
Heart Attack Stroke
Family History Mother:
Heart Attack Diabetes Kidney Cancer Colon Cancer Hypertension
No known medical history for father Children in good health
Admission Values
Ht: 60” Wt: 54.4 kg Current Wt: 53.8 IBW: 54 kg %IBW: 99.6% BMI: 23.11 BP: 208/86 Minor Edema
Stable Weight Trend
No swallowing or GI problems
Lab Values Patient Normal Dialysis Rec.
Calcium (mg/dL)
7.6 (L) 12-16 8.4-10.2
Potassium (mEq/L)
4.2 3.5-5.0 3.5-5.5
Phosphorus (mg/dL)
5.2 (H) 2.5-4.5 3.0-5.5
Sodium (mEq/L) 138 135-145 135-145Hemoglobin (g/dL)
9.8 (L) 12-16 10-12
Ferretin (ng/mL) 1217 (H) 3-151 200-500PTH – Intact (pg/mL)
333 (H) 10-65 150-600
Albumin (g/dL) 3.4 (L) 3.5-5 Min: 3.5 Opt: 4.0
Hb A1c (%) 6.2 (H) 4.4-6.1 Less than 7.0Glucose (mg/dL)
172 (H) 70-105 80-180
URR (%) 76 - 65 or aboveCreatinine (mg/dL)
4.38 (H) 0.8-1.6 2-15
Medications
Oral: Acetaminophen Nifedipine Clonidine Pravastatin Docusate Escitalopram Lisinopril Tramadol Tums
IV Epogen Hectoral
Medication DescriptionsMedication Use Drug/Nutrient
InteractionsAcetaminophen
Pain Reliever/Fever reducer
BP medication, cholesterol medication, antibiotics, etc
Nifedipine Reduce BP/reduce angina grapefruit productsClonidine Reduce BP alcoholPrimvastatin HMG CoA reductase
inhibitor, or, statin, reduce LDL and increase HDL
Alcohol, grapefruit products, other statins, spironolactone,
Docusate Stool softener n/aEscitalopram Antidepressent Alcohol; Cold or
allergy medicine, narcotics, sleeping pills, muscle relaxers
Medications ContinuedMedication Use Drug/Nutrient
InteractionsLisinopril Ace-Inhibitor/reduce
BP/treat CHFAlcohol, salt substitutes, other bp medications, potassium supplements
Tramadol Pain reliever Alcohol, antidepressants
Clonidine Reduce BP alcoholTums Phosphate binder,
calcium supplement, indigestion
n/a
Epogen RBC production n/aHectoral Decrease PTH levels Magnesium
containing antacids, digoxin
General Diet History Good appetite Lost 50 lbs in past year Small portions Tries to “eat healthy, but
depends on my daughter” 3 meals a day 1 snack Says new renal diet is
“tricky” but she’s trying
24-hr Recall Breakfast: 2 eggs over easy, 1 piece of
white toast & 1 tsp butter Lunch: Pepper chicken with snap peas,
red peppers, and carrots, ½ cup white rice
Dinner: None (usually eats whatever daughter picks up after work)
Snack: 1 Mexican Cookie and a half of an apple
Dialysis Prescription
Type: Hemodialysis Days: M-W-F Treatment Length: 2.5 hr BFR: 350 mL/min Dialysate Flow Rate: 800 mL/min Access: CVC catheter – Jugular (Right) Average Fluid Gain: 1.6 kg EDW: 52 kg
Patient Estimated Needs
Kcal: 1550-1600 Protein: 60 g Sodium: 2000 mg Potassium: 2000 mg Phosphorus: 800 mg Fluid: 1000 mL
Diet Prescription Renal Diet
Low Potassium Low Phosphorus High Protein
Carbohydrate Controlled Low Fluid
Monitoring & Evaluation Start taking Tums as a phosphate
binder Start Hectoral to decrease PTH levels Increase Epogen to increase
hemoglobin Get fistula as soon as possible Patient eager to participate actively Prognosis:
GOOD!
ESRD: What is it? End Stage Renal Disease Stage 5 kidney disease
Kidneys stop working i.e. kidney failure <15% kidney function
PERMANENT Need a transplant or dialysis to live
No cure Goal of treatment: Slow progression
ESRD: Etiology & Pathophysiology
Progression of CKD Main causes:
Diabetes Hypertension
Kidney Failure=DEADLY
GFR <15 mL/min Dialysis or
Transplant required
ESRD: Diagnosis GFR rate calculation Urine Test Blood Test MRI Biopsy
ESRD: Signs & Symptoms
General “ill” feeling Itchy skin Dry skin Loss of appetite Nausea Edema Muscle-twitching &
cramps Headaches
Decreased urine output
Poor concentration
ESRD: Treatment Hemodialysis Peritoneal Dialysis Transplant
Not a cure Last about 5-10
years Strict guidelines
Treatment: Hemodialyis Hemodialysis
Filter blood Access Points Clinic Strict Diet
Treatment: Peritoneal Dialysis
Peritoneal Dialysis Filter through peritoneum Home Through abdomen Less Strict Diet
ESRD: Common Medicines
Binders Hectoral Sensipar Epogen Iron Calcitriol
Renal DietHemodialysis Peritoneal
DialysisEnergy (kcal/kg SBW) 30-35 30-35Protein (g/kg SBW) 1.2 1.2 & higherPhosphorus (mg/kg SBW) 800-1000 800-1000Potassium (mg/d) 2000-3000 3000-4000 Sodium (mg/d) 2000-3000 2000-3000Fluid (mL/d) 750-1000 2000
Protein Protein loss with
dialysis Affected by infection
& trauma Essential for:
Growth & development
Prevent infection Healing
Tissue Wound
HBV sources Meat Fish Poultry
Protein Supplement
Potassium Limit high
potassium foods Tomatoes Potatoes Bananas oranges
High Potassium Muscle weakness Bradycardia Cardiac arrest
Low Potassium Vomiting Diarrhea Hypotension
Phosphorus Poorly dialyzed Phosphate binders
Renvela PhosLo Tums
High phosorus Calciphylaxis Hardened arteries Weak bones
Avoid high phosphorus foods Cheese Dairy Beans Nuts cola
Fluid Fluid restriction Approx 48 oz. per day Based on:
Urine output Interdialytic weight gains
Excess fluid: Rapid weight gain High blood pressure Edema Poor appetite
Physical Activity Difficult for most Benefits
Stimulate appetite & circulation Improve cardiovascular risk factors
Hypertension Hyperlipidemia Diabetes Obesity
Enhance sense of well-being
PES Statement
Limited kidney function related to end stage renal disease as evidenced by low serum calcium, anemia, low serum protein, high serum phosphorus, high PTH, and high serum creatinine levels.
Follow-up Hemoglobin went up to 10.9, reduced
Epogen dose Fistula placed in left arm on March 14th
Understands disease & reason for treatment
Adjusting slowly but well As of 3/15 moved out of daughters home Patient says, “Will make it!”
Summary ESRD is DEADLY if not treated properly. Diet is the key component to keeping
person in optimal health Prognosis:
Good if sticks to plan
QUESTIONS?
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