Mechanical AV and tricuspid repair, HD and CVA and the nutritional implications ofKidney Disease and Hungry Bone Syndrome Kari Ikemoto Dietetic Intern Keene State College
Name That Kidney 1 2 5 3 4
Dartmouth Hitchcock Medical Center • 225 acre facility located in Lebanon, NH • 396 bed facility • Level 1 Trauma Center • New Hampshire’s only academic medical institution • Norris Cotton Cancer Center • Children’s Hospital at Dartmouth • Geisel School of Medicine at Dartmouth • Dartmouth Hitchcock Advanced Response Team
Registered Dietitians at DHMC • 20 Dietitians Total • Director of Food and Nutrition Services • Inpatient • Nutrition Support • ICN/Pediatrics • Outpatient • Diabetes, Renal, Bariatric, Oncology • 3 Diet Technicians
Role of the RD at DHMC Inpatient Outpatient • Respond to clinician consult • Pulled by diagnosis • Pulled by unit (ICU/PICU) • Age • Diet order • Abnormal labs • PO checks • Nutrient drug interactions • Diet progression (off TPN/TF) • Hospital day 9 • Referral from physician • Patient desire • Follow up
A Multi-Disciplinary Approach • Inpatient • Work independently • ICU-TF & TPN • Specialties • GI, CF, Pedi, ICN, Pedi CF • Clinics • Team approach • GI, GIM, CF, ALS, Pedi CF, OB, Stone • Outpatient • Infectious diseases, Endocrinology, Bariatrics, Hem/Onc (pedi), NCCC
PES Statements & Charting • DHMC does not follow a specific PES statement in their documentation • Some RDs will use the diagnosis for their own reference • Each RD has their own template that they use • Typically SOAP style format • Malnutrition recommendations • DHMC guide, based on the ADA Manual of Clinical Dietetics
DHMC Malnutrition Guidelines • Kwashikor • Malnutrition of Mild Degree • Marasmus • Malnutrition of Moderate Degree • Severe Protein Calorie Malnutrition • Cachexia • Other Protein-Calorie Malnutrition • Unspecified Protein-Calorie Malnutrition
Patient Information • Ms. B • Age: 64 years old • Occupation: Administrative Assistant at college • Family • Single with 1 child and 2 grandchildren. • Brother and sister-in-law are biggest support system • Former smoker, quit at age 40 • Smoker for 20 years • Anthropometric measurements • Height: 175.3 cm • Weight: 64.41 • BMI: 20.97
Pertinent Medical History Previous Surgical History Past Medical History • Parathyroidectomy • Related to persistent hypercalcemia. • Parathyroid gland inserted into her right brachioradialis muscle • Tonsillectomy • Left flank exploration surgery that dx PKD • ORIF of right finger • Left upper extremity fistula for HD access • Intussusception repair during infancy • Polycystic Kidney Disease • Hemodialysis-15 years • Hypertension • Hyperlipidemia • Asymptomatic gallstone • Anemia • Severe aortic stenosis
History of Presentation Symptoms experienced Reason for visit • MWF hemodialysis • Presented with several months (likely over a year) of severe dyspnea on exertion with routine activities • Significantly decreased exercise tolerance • Bilateral lower extremity edema x 2-3 months • Aortic stenosis with chronic LV systolic dysfunction (LVEF 25%) and pulmonary hypertension with tricuspid regurgitation • Ultimately, after much deliberation, she decided upon a mechanical prosthesis, related to high probability of calcification of valve
The Kidney • Main functions • Excretory • Acid base balance • Endocrine • Fluid and electrolyte balance • Endocrine functions • 1, 25-dihydroxy-vitamin d3 (calcitriol) is produced in kidney and enhances calcium absorption • In healthy kidneys the activation of Vitamin D and excretion of excess phos help to maintain healthy bones
Polycystic Kidney Disease • Hereditary disorder where cysts form in the kidneys, destroying kidney tissue and function. • Two types • Autosomal recessive-early childhood • Autosomal dominant- later in life • Typically treated with hemodialysis or kidney transplant • Note- Cerebral aneurysms are commonly found in adults with PCKD; often screened with MRIs of the brain
Parathyroid Metabolism • The response of PTH to the kidney is to increase renal calcium resorption and calcium excretion. • In the kidney PTH blocks resorption of phosphate in the proximal tubule while promoting calcium resportion in the ascending loop of Henle, distal tubule, and collecting tubule • Promotes absorption of calcium from the bone in 2 ways • Bind to receptors on bone cells to pump Ca ions from the bone to the extracellular fluid (rapid) • Activate osteoclasts to digest formed bone, followed by proliferation of osteoclasts • Converts 1, 25 hydroxy Vitamin D to its active form • Primary function of active form is to promote gut absorption of calcium.
Parathyroidectomy • Indicated for patients with hyperparathyroidism and elevated serum calcium • Monitor calcium levels following surgery, they should return to normal • In some cases however, prolonged hypocalcemia exists in a condition known as Hungry Bone Syndrome
Hungry Bone Syndrome • Rapid, profound, and prolonged hypocalcemia (>4 days post op) associated with hypophosphatemia and hypomagnesemia, exacerbated by suppressed PTH following parathyroidectomy. • Believed to be due to the greatly increased skeletal usage of calcium as a result of high circulating PTH levels on bone • Uncommon but serious adverse effect of parathyroidectomy. • Older age is a risk factor
Calcium, PTH and Kidney Disease • Patients with CKD almost always develop secondary hyperplasia of the parathyroid glands, resulting in elevated blood levels of parathyroid hormone (PTH). • This abnormality is due to the hypocalcemia that develops during the course of kidney disease and/or to a deficiency of 1,25-dihydroxycholecalciferol that may directly affect the function of the parathyroid glands. • With progressive loss of kidney function, a decrease in the number of vitamin D receptors (VDR) and calcium-sensing receptors (CaR) in the parathyroid glands occurs, rendering them more resistant to the action of vitamin D and calcium. • As stated by the K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease
Admission to DHMC for procedure October 11th- Hospital Day 1
10/11/13- Hospital Day 1 • Operative Findings: Large pericardial effusion. Severely calcified trileaflet aortic valve.
Ensured that pt was not volume overloaded, HD prior to surgery • Consultation by nephrology, no urgent need for RRT (renal replacement therapy) • Taken to the CVCC in critical but stable condition • Intubated and on minimal pressors
Initial Nutrition Consult- Hospital Day 4 • Consulted s/p AVR • Diet order: DHMC, Low Phos, 2 gram K, 2 gram Na • PO: Not eating well, only able to tolerate liquids prn • Nutrition Needs estimated at: 1,530-1,830kcal, 92-110 g protein. • Nutrition Plan/Recommendations • Continue diet as ordered • Not appropriate for education for DHMC/Renal diet at this time • Will send liquid nutrition supplement drinks offered to optimize PO
Hospital Day 6 • During HD, stroke alert for pt was made • Nurse performed neuroassesment • Sudden onset left sided weakness • CT showed no hemorrhage • CT Head w/o contrast showed no evidence of intracranial hemorrhage, or large area of cortical hypodensity. There is an area of increased density in a right MCA sylvian branch. • Consented to thrombectomy for clot removal • Neurology reports that stroke most likely cardioembolic (mechanical heart valve) or atheroembolic.
Hospital Day 8- Nutrition Consult for TF • Pert. Meds: calcitriol, calcium citrate, epinephrine, reglan, oxycodone, phenylephrine, RBOs, vasopression @ 0.08 unit/min • Current weight (kg): 70.6/Adm weight (kg): 61.3/IBW (kg): 65.9/Height (cm): 175.3/BMI: 20 • Nutrition needs 1800 calories and 92 gms protein daily. • Current TF of Nepro running at 15 ml/hr via OGT. Patient on pressors.
TF Recommendations • Pt is on pressors which may increase risk for gastrointestinal hypoperfusion with enteral feeds. • Monitor for increasing abdominal distention, constipation, elevated gastric residuals, or ileus. • Suggest: Nepro at goal rate of 50 ml per hour plus 2 scoops of protein powder daily. • This rate is calculated to compensate for unplanned time off feedings due to potential procedures, etc. • This will provide 1850 calories, 93 grams protein, 727 ml water from formula +100 ml water from protein powder administration, 27.2 mEq of potassium, 720 mg of phos and 46.1
Hospital Day 10- MD Note • Very deconditioned and poor nutritional status likely contributed to development of ulcer. Will monitor closely, increase TFs to goal to help with healing. • Pt also noted to be too critically ill for HD, possible transition to CVVH
Wound Care RN Note • Area of deep purple discoloration to coccyx/sacrum is consistent with a suspected deep tissue injury. This area may continue to evolve and breakdown further into full thickness skin loss, there is no sign of infection at this time. This is at least a stage II pressure ulcer as there is partial thickness skin loss. • Poor nutritional status-PAB level is 7, she is at high risk for additional skin breakdown due to overall status, pressor requirement and poor nutritional status.
Hospital Day 10- Nutrition note • Formula was changed to Replete • No need for renal formual with CVVH, increased protein needs on CVVH • Small pressure ulcer reported. • Nutrition needs assessed at: 1600 calories and 124 gms protein daily while on CVVH. • While on CVVH, suggest: Replete rate of 75 per hour plus 6 scoops of protein powder daily. • When off CVVH, suggest TF goal of Nepro 250 mg Vit C suggested daily for wound healing.
Hospital Day 11-SLP • Positive outward s/s of Sensory-Motor OropharyngealDysphagia and s/s Aspiration at this time • Recommendations: • continue NPO; continue with alternative nutrition at this time • Further w/u with Modified Barium Swallow when pt more stable if s/s aspiration presist • Further speech, language, voice evaluation • Note- Pt pulls out NG tube
Hospital Day 12- Nutrition NPO Note • Tolerated CVVH, negative -500. • Pt seen for tube feeding follow-up. She self d/c'd her feeding tube and refused to have it replaced.. Therefore, she has essentially been NPO and/or has received less than 500 calories/day over the past week. • Consider TPN if appropriate. • Labs- PAB 7 (indicative of poor nutrition status)
Hospital Day 14- Nutrition Notes • MD recommends Replete • This formula not consistent with recommendations when pt is on HD • Suggest: Nutren 2.0 at goal rate of 37 ml per hour plus 6 scoops of protein powder daily
Hospital Day 17- Nutrition Note • TF order: Replete at 50 ml/hr plus 2 scoops protein powder daily -> currently off for GI bleed, may restart later today • Residuals WNL is • Average TF intake 80% calorie requirements • Suggested to change tube feedings to Nutren 2.0 which is more appropriate for pt given hemodialysis. • Nutren 2.0 at goal rate of 37 ml per hour plus 6 scoops of protein powder daily • Loose stools s/p rectal tube - pt receiving liquid tylenol and neutraphos. Liquid tylenol contains sorbitol, a poorly absorbable sugar alcohol that can cause diarrhea and Neutraphos can cause diarrhea. • Pt has not been getting calcitriol
Hospital Day 18- Nutrition Support- MD/RD • Reason for Consult: Seeing the patient at the request of Dr. Y to evaluate for initiation of parenteral nutrition support of malnutrition. I have reviewed the available records and examined the patient. • Indicators of Severe Malnutrition: • Poor nutritional intake > 7days • Additional Justification for Nutrition Support: • Nasoenteric/Gastric Feeding not tolerated or contraindicated • TPN support is necessary when parenteral feeding is indicated for longer than two weeks, peripheral venous access is limited, nutrients needs are large or fluid restriction is required and the benefits of TPN support outweigh the risks.
TPN Recommendations • Nutritional Needs: • Kcal/day:1800 • Protein/AA/day(gm):90 • Nutrition Prescription: • Parenteral: • Calories:1490 • Dextrose (grams/day):176 (8 units of insulin) • Amino Acids (grams/day): 90 • Lipids (grams/day): 55
Hospital Day 20 • Limit TPN/TF volume for HD and fluid removal • Challenging fluid management related to nutrition support and antibiotics. • Nutrition was re-consulted for TF • Consulted for tube feedings that are high in protein without protein powder, low volume, and high in calcium. • Suggest Impact Peptide 1.5 at goal rate of 55 ml per hour to provide 1650 kcal, 103 gm protein, 846 ml water from formula, 100% of RDI's for vitamins and minerals. • If Cipro is changed to enteral per tube administration, hold tube feedings for 2 hrs before and 2 hrs after each dose of Cipro to avoid potential TF and drug interaction, and consult nutrition services for adjusted TF goal rate.
Hospital Day 21 • Nutrition • Tolerating thus far at 35 ml/hr with plans to increase by 10 ml/hr every 4 hrs to goal. • If pt becomes hyperkalemic- change tube feedings to Nepro • Nephrology • Hypokalemia and hypocalcemia • Calcium supplementation
Hospital Day 27 • Nutrition • Tolerating TF, stayed with same formula. • Discussing PEG placement RT pt displacement of DHT • Hospital Day 31 • The past 3 days pt has averaged 92% of goal for enteral feeds. Note that pt is getting PEG placed. Resume enteral feeds when able. • Propofol at current rate is providing 275 kcal/d from lipid. Depending on how long she is on propofol, may want to consider periodically checking her TG levels.
Hospital Day 34 • Nutrition • The past 3 days pt has averaged 52% of goal volume for enteral feeds • Feeds on hold for OR for trach placement. • Stool output is over a 1 L in the past 24 hrs. Recommend checking stool for toxins. If toxin negative, consider starting loperamide 2-6 mg up to QID. Consider changing pt to a crushable pill form of tylenol rather than liquid. • Hospital Day 35 • PEG placed • Hospital Day 38 • Residuals minimal • Achieving only 40% of goal • Pt on HD w/ TF via PEG w/ low PAB and inadequate TFs past 4 days.
Hospital Day 42 • 2 day average is at goal (100%). Continue to monitor for tolerance. • Monitor BM. Per nursing, pt had loose stools over the last 2 days. • Of note, pt has wound that is being monitored. Protein intake ~1.7 gm/kg; for wound healing is consistent with recommendations. TF providing adequate vitamin C for healing. If consistent with goals of care addition of 220 mg of zinc daily x 10 days may benefit healing.
Hospital Day 45 • In the HD population, the serum PAB is spuriously elevated due to abnormal metabolism of the prealbumin-retinol binding protein complex. • Its generally recommended that when prealbumin is used to monitor the nutritional status/response to a nutritional intervention in this population, the goal of therapy should be a prealbumin level equal to or greater than 29 mg/dl. • Presently her levels are at 12. • Continue to monitor weekly but also suggest drawing CRP level on the same day as PAB level to see what degree an APR is playing in depressing the PAB.
Hospital Day 47 • Residuals minimal • Average daily TF intake (past 4 days):965 ml, daily goal is 1100 ml - achieving 88% • Asked to re-eval TF for 2 gr protein/kg dry wt. • As pt is not achieing 100% of TFs on most days, suggest add 3 scoops protein powder to provide 121 gr protein daily. • Suggest 220 mg zinc sulfate daily for wound healing • Hospital Day 53 • 99% of TF goal • Wound healing- Addition of 200 mg zinc sulfate for wound healing
Hospital Day 57 • Ms. B’s K was greater than 5.0 four out of the last five days. Suggest changing enteral formulation to provide less K. • Nutren 2.0 at 36 ml/hr plus 10 scoops protein powder daily. • TF will provide, at goal, 35 mEq of K daily rather than 53 mEq daily with the impact peptide 1.5
Hospital Day 59-Wound Care Nurse • Diet/Nutrition Prescription: NPO; tube feeding • Diet/Feeding Assistance: total feed • Diet/Feeding Tolerance: good • Intake (%): 100% • Fluids: adequate • Fluids Requirement: TF/IVF • Nutrition Risk Screen (every 4 days/sig change) • Consult Dietitian if Indicator Present: tube feeding or parenteral nutrition • Nutrition Interventions: tube feeding ordered • Metabolic/Electrolyte Imbalance Management: electrolyte adjustment • Promote Oral Intake (dysphagia diet restrictions) • NPO pending swallowing screening/evaluation • Promote Oral Nutrition • Swallowing Techniques: Dysphagia: oral mucosa moistened
Hospital Days 60/64 • Day 60 • TF at goal, residuals WNL • Day 64 • The past 3 days pt has averaged 100%+ of goal volumes for enteral feeds. Getting all protein powder. • Recommend a nephrocap daily for wound healing. • Recommend D/C zinc supplementation tomorrow as over supplementation of zinc can induce a copper deficiency and this is also needed for adequate wound healing.
Hospital Day 65- DISCHARGED Ms. B was discharged to a Acute Long Term Care facility in Massachusetts.