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Case Study

Case Study. Store Manager with Acute Renal Failure. Mrs. Calley, 35 yo, 5’3”, 125# Admitted post MVA in ER after car accident. Fractured leg, broken ribs, collapsed lung, and internal bleeding. After surgery to stop internal bleeding, Mrs. Calley developed ARF (Acute Renal Failure).

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Case Study

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  1. Case Study Store Manager with Acute Renal Failure Mrs. Calley, 35 yo, 5’3”, 125# Admitted post MVA in ER after car accident. Fractured leg, broken ribs, collapsed lung, and internal bleeding After surgery to stop internal bleeding, Mrs. Calley developed ARF (Acute Renal Failure)

  2. Post Surgery: Urine Volume only 50 ml/day BUN = 75 mg/dl (10-20 mg/dl NL) Why did mrs. Calley develop arf? HYPOVOLEMIA; 2˚ TO MASSIVE BLOOD LOSS. OTHER KNOWN CAUSES OF ARF? HEART FAILURE, DRUG OVERDOSE, SEPSIS, TOXINS

  3. MEETING MRS. CALLEY’S ENERGY NEEDS: CALCULATED NEEDS RANGE: 1989- 2809 KCAL/DAY HOW COULD WE ACCURATELY ASSESS THESE CALORIC NEEDS??????? INDIRECT CALORIMETRY: TO AVOID UNDER- OR OVERFEEDING PROBLEM: URINARY OUTPUT LOW, NEEDS ARE HIGH. TOLERANCE LIKELY WILL BE LOW.

  4. MONITOR BUN AND CREATININE TO DETERMINE IF DIALYSIS IS NEEDED. WILL TOLERATE MORE PROTEIN, SODIUM, POTASSIUM MONITOR SERUM POTASSIUM!! HYPERKALEMIA CAN CAUSE CARDIAC ARRHYTHMIAS!!

  5. REMEMBER: EARLY PHASE OF ARF= OLIGURIC PHASE PROTEIN, SODIUM, POTASSIUM, AND FLUID ARE RESTRICTED. AS DIURESIS PHASE ENSUES, LARGE VOLUMES OF FLUID WILL BE LOST; BUN AND CREATININE WILL SLOWLY DECREASE. WATCH FOR HYPOKALEMIA.

  6. Chronic Renal Failure Results from Irreversible Nephron Damage Gradual Decline in GFR Exhausts the “Renal Reserve” Symptoms Occur After ~75% Loss of Function!! Atherosclerosis Hypertension Nephritis Kidney Stones Renal Obstruction Diabetic Nephropathy HAPPENS OVER MONTHS TO YEARS!!!

  7. DETERIORATION OF KIDNEY FUNCTION: GFR BUN SERUM CREATININE DECREASED ABILITY TO EXCRETE: UREA, CREATININE = UREMIC SYNDROME ACID (H IONS) = ACIDOSIS SODIUM = EDEMA POTASSIUM = HYPERKALEMIA (ARRHYTHMIAS)

  8. RENAL FAILURE ASSOCIATED WITH: FLUID, SODIUM, POTASSIUM RETENTION HYPERLIPIDEMIA HYPERGLYCEMIA ACCELERATED ATHEROSCLEROSIS HTN CHF M.I. PULMONARY EDEMA

  9. RENAL FAILURE ASSOCIATED WITH: RENAL OSTEODYSTROPHY GROWTH FAILURE AND WASTING SYNDROME ANEMIA

  10. TREATMENT GOALS IN CHRONIC RENAL FAILURE: 1. DELAY PROGRESSION OF RENAL FAILURE. 2. PREVENT BUILD-UP OF TOXIC METABOLIC PRODUCTS AND THEIR COMPLICATIONS. 3. MAINTAIN NUTRITIONAL STATUS.

  11. Treatment of CRF PHASE 1: CONSERVATIVE MANAGEMENT USING DIET AND PHARMACEUTICALS. DIET ALTERATIONS MAY INCLUDE PROTEIN, PHOSPHORUS, FLUID, SODIUM AND POTASSIUM RESTRICTIONS. PHASE 2: DIALYSIS PHASE SAME DIET CONCERNS PHASE 3: TRANSPLANTATION PHASE

  12. Case Study: Child with Chronic Renal Failure Jason, 9 y0 boy, CO sore throat, tired, poor appetite stomach cramps, “bad” taste in mouth. Dx’ed with glomerulonephritis

  13. In the following 3 years, Jason’s kidney fxn has declined. Current Labs: GFR: 4 ml/min BUN: 102 mg/dL Remember: CRF develops from ANY condition that progressively and permanently damages the kidneys.

  14. Anthropometrics 4’ 3” 55# (45th %tile Height, 25th%tile weight) Anorexia, Nausea contribute to poor intake low vitamin D production = poor growth Metabolic Bone Disease Current intake (by assessing usual intake): 30 g protein, 1100 kcal/day (44 kcal/ kg) ~80 kcal/kg ~2000 kcal/day Needed to support growth?

  15. What course of action would you recommend?? Dialysis was instituted. Effect on protein/ fluid intake levels? What if Jason receives a kidney transplant?

  16. Assessing Protein Homeostasis Serum Creatinine: produced at constant rate during muscle turnover direct indicator of muscle mass reflects renal excretion capability Not diet-related unless patient has high meat diet Creatinine Clearance: Indicator of GFR and renal damage

  17. Assessing Protein Homeostasis Blood Urea Nitrogen: In healthy people, increases reflect excessive protein intake. Can increase in dehydration, traumatic injury, infections, etc. Uremic symptoms occur above 80 mg/dl Other measures: urine urea nitrogen (UUN)

  18. Monitoring Phosphorus Levels: Restrictions can help stave off high serum phosphorus levels. Phosphate Binders (e.g., calcium carbonate, calcium acetate) are taken with meals to impede calcium absorption. New “gels” without calcium also accomplish this function. Avoid aluminum and magnesium-containing salts.

  19. Use of Calcium Supplements Calcium absorption is impaired due to low renal 1-alpha hydroxylase activity. Poor control of serum calcium levels can cause some using Ca supplements to have hypercalcemia. Supplemental vitamin D can help maintain blood calcium Levels (watch for hypercalcemia; ectopic calcification.

  20. Other nutrient concerns: Iron-deficiency anemia: try erythropoietin. Zinc deficiency may cause dysgeusia and anorexia (altered taste perception)

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