Newly Diagnosed Hemodialysis

Spenser Parker January 15, 2014

OverviewO Patient History and AdmissionO Background of the DiseaseO First Research ArticleO Application to PatientO Nutrition Care ProcessO Second Research ArticleO SummaryO Personal Impression

Patient ProfileO KR is a 56 year old femaleO HispanicO Family in TexasO On disability due to injuryO Admit on September 18, 2013O Discharged on September 27, 2013

Health HistoryO Chief compliant of bilateral flank painO History of:

O Hypertension-not medicatedO Cervical CancerO HydronephrosisO Nephrolithiasis

O Surgical History of:O Stent placements in 2012O Radium implants

McCance & Huether 2002, p.1172

Physiology O Function of the kidneys

O Filter 20-25% of the blood per minuteO Waste products/unused electrolytes

O What the kidneys are made ofO Glomerular filtration rate(GFR-ml/min)

O Collecting Tubules-Ureters

Mahan & Escott-Stump, 2008 p.929

Renal FailureO Acute Kidney Injury (AKI)

O GFR is suddenly reduce O Toxic Drug ExposureO Allergic Drug ReactionO Ischemic Acute Tubular Necrosis

O NephrolithiasisO Kidney StonesO Most common are calcium stone

formation

Renal Failure O Hydronephrosis

O Accumulation of urine in the collecting tubules

O Usually caused by some kind of obstruction

O Damages GFRO Chronic Kidney Disease

O Five StagesO Diabetes, Hypertension,

GlomerulonephritisO Happens over a period of time

Mahan & Escott-Stump, 2008 p.929-30

Mahan & Escott-Stump, 2008 p.929-30

ESRDO Symptoms include:

O Nausea and VomitingO Decrease in urine productionO Muscle weaknessO Metallic Taste in Mouth

O Treatment options:O TransplantationO Hemodialysis or Peritoneal Dialysis

Mahan & Escott-Stump, 2008 p.929-30

Nutrition for Renal Failure

O Usually no nutrition intervention for AKI

O For ESRD three electrolytes need to watchO SodiumO PotassiumO PhosphorusO Fluid Restriction

Lingerfelt & Thronton, 2011 p.483-488

An Educational Project for Patients On Hemodialysis to Promote Self-

Management Behaviors of End Stage Renal Disease

O Objective: provide an overview of the benefits of educating patients with ESRD on HD about their disease, diet, treatment, and medication to promote self-management behaviors

O 26 participantsO First took a pre-test to assess

patients knowledge

Lingerfelt & Thronton, 2011 p.483-488

An Educational Project for Patients On Hemodialysis to Promote Self-

Management Behaviors of End Stage Renal Disease

O Educational Intervention-ESRD handbook and one-on-one 30 minute sessions to review and answer questions for 4 weeks

O Afterwards patients then took the same pre test again

O Results: pre-test ranged from 3 to 21 and post-test 15 to 23

Application to PatientO Initial Diagnosis of

hydroureteronephrosisO Obstruction was believed to be from

radium implants from treatment of cervical cancer

O Urologist consulted for nephrostomy tubes

O Dialysis catheter was consideredO Although kidney function was

thought not to improve

MedicationsO AcetaminophenO Calcium gluconateO CeftriaxoneO EpoetinO FamotidineO HeparinO Renal MVI

Nutrition Care ProcessO InterviewO AssessmentO PES StatementO Relevant labsO EducationO Follow Up Visit

InterviewO KR was undergoing dialysis at time

of interviewO Didn’t eat much 3-4 days PTAO Didn’t have much appetite (50%)

since admitO Nausea and vomiting were improvingO Was on renal dietO Had poor dentition

AnthropometricsO KR is 5 foot 6 inchesO Weighs 107.05kg or 235 poundsO Ideal Body Weight of 58.97kgO KR is 181% of IBWO Adjusted body weight of 71kgO BMI of 38.3

Macronutrient NeedsO 30-35kcal/kg using ABW -2100-

2500kcalO 1.2-1.5g/kg using ABW -85-106gmO Fluids need up to MD (anuric)

O CorrectionO 25-30kcal/kg using ABW 1775-

2100kcal

Relevant Labs9-18 9-19 9-20 9-21 9-22 9-23 9-24 9-25 9-26 9-27

Cr 9.55H 10.10H

9.83H 9.34H 8.24H 7.12H 7.02H 4.99H

BUN 60H 64H 68H 68H 63H 51H 50H 30H

GFR 4L 4L 4L 4L 5L 6L 6L 9L

Alb. 3.2L 2.3L 2.6L 2.5L 2.8L 2.8L 3.2L

K+ 4.5 4.6 4.5 3.6 3.5 3.3L 3.9 3.9

Phos. 5.5H 4.8H 3.6 4.0

PES StatementO Increased nutrient needs related to

current condition of ESRD secondary to starting hemodialysis as evidenced by intake record and low albumin.

EducationO Standard Renal Education

O Low potassiumO Low phosphorusO Low sodium

O Family SupportO Throwing Out food

Follow Up VisitO Propass Mousse BIDO Gave chopped meats O On KR’s follow up visit

O No Nausea/vomitingO Increased appetite

O Follow up questionsO biscuits

Janardhan et al., 2011 p.38-45

Prediction of malnutrition using modified subjective global assessment-dialysis malnutrition score in patients

on hemodialysis

O 66 patients were included in the study that was conducted in India

O Anthropometrics measurements were taken after dialysis (height, body weight, tricep skin fold)

O Biochemical markers used: Albumin, Total Protein, Cholesterol, Transferrin, Ferritin, Total Iron Binding Capacity, BUN, Creatinine

Janardhan et al., 2011 p.38-45

Prediction of malnutrition using modified subjective global assessment-dialysis malnutrition score in patients

on hemodialysis

O SGA-Dialysis Malnutrition Score:O Weight change, dietary intake, GI symptoms,

functional capacity, co-morbidities, muscle wasting, subcutaneous fat

O Mean SGA score was 17.9+-2.85 (17.3+-3.2 in women and 18.2+-2.6 in men)

O Body weight showed a negative correlation with SGA (p=0.037)

O TSF showed a negative correlation with SGA (p=0.054)

O Albumin(p=0.049) Total Iron Binding Capacity (p=0.026) Ferritin (p=0.042) Transferrin (p=0.046)

SummaryO Many ways someone can end with

renal failureO KR resulted in having ESRD through

hypertension and long period with an obstruction

O The key to success on dialysis is proper education and family support

O It is a lifestyle change, but can be managed

Personal ImpressionO Interesting how KR resulted with

ESRDO Education was well receivedO Obese non diabeticO Attitude that KR had after once

placed on dialysisO Changes for calories (experience)

ReferencesO Beto, J. (2010). Improving First-Year Mortality in Patients On Dialysis: A Focus on

Nutrition and Exercise. Nephrology Nursing Journal, 37, 61-65, 98.O Dixon, J., Borden, P., Kaneko, T. M., Schoolwerth, A. C. (2011). Multidisciplinary

CKD Care Enhances Outcomes At Dialysis Initiation. Nephrology Nursing Journal, 38, 165-171.

O Janardhan, V., Soundararajan, P., Rani, N., Kannan, G., Thennarasu, P., Chacko, R., Maheswara, R. C. (2011). Prediction of malnutrition using modified subjective global assessment-dialysis malnutrition score in patients on hemodialysis. Indian Journal of Pharmacuetical Sciences, 73, 38-45.

O Lingerfelt, K. L., & Thronton, K. (2011). An Educational Project for Patients On Hemodialysis to Promote Self-Management Behaviors of End Stage Renal Disease. Nephrology Nursing Journal, 38, 483-488.

O Mahan, L. K., & Escott-Stump, S. (2008). Krause’s food & nutrition therapy, 12th ed. St. Louis, Missouri: Mosby, Inc.

O Mazairac, A. H., Grooteman, M. P., Blankestijn, P. J., Lars Penne, E., Van Der Weerd, N. C., . . . Bots, M. L. (2012). Differences in quality of life of hemodialysis patients between dialysis centers. Quality of Life Research, 21, 299-307. doi:10.1007/s11136-011-9942-3

O McCance, K. L, & Huether, S. E. (2002). Pathophysiology: The biologic basis for disease in adults & children, 4th ed. St. Louis, Missouri: Mosby, Inc.