CHRONIC KIDNEY DISEASE BY EVA BHOLA
INTRODUCTION • My case study patient, JT is a 69 year old black woman admitted to the hospital with progressive Altered Mental Status (AMS) changes, as well as significant lethargy. Patient presents with significant medical history for hypertension (HTN), diabetes, chronic kidney disease and hemodialysis dependent since 2009. As stated per family member, JT’s systolic blood pressure runs ≥ 150 mmHg on a regular basis. She undergoes dialysis three days (Mon, Wed, Fri) a week.
THE PATIENT • Name: JT • Height: 62” (157.48 cm) • Weight: 124.4 lbs (56.443 kg) • Age: 69 • Sex: Female • Admitting Diagnosis: Other alteration of consciousness • Past Medical History: Diabetes Mellitus, Hypertension, Chronic Kidney Disease, Hemodialysis dependent, Multiple Transient Ischemic Attacks • Social History: Patient resides at home with her husband and children. She has Medicaid and her husband is the primary caretaker.
Chronic Kidney Disease • CKD is the syndrome of progressive and irreversible loss of the excretory, endocrine, and metabolic functions of the kidney secondary to kidney damage. It progresses slowly over time and may have intervals where kidney function remains stable. Onset of renal failure is usually not obvious until renal function reaches 50-70% loss.
Functions of Kidneys • 1) Excretory: Kidneys are responsible to excrete the waste products of the normal tissue breakdown and food metabolism. • 2) Metabolic: Nitrogen balance and acid base balance. Also controls blood pressure by renin-angiotensin mechanism. • 3) Endocrine: Kidneys produce the hormones erythropoietin and 1,25-dihydroxycholecalciferol.
Causes of Kidney Failure • Diabetes Mellitus • Hypertension • Glomerulonephritis
Diabetes and CKD • Saturation of glucose transporters in the blood results in glucose in the urine. • Glucose in urine results in osmotic diuresis. • Chronic hyperglycemia leads to microvascular damage, including damage to glomerular capillary walls, resulting in microalbuminuria (30-300 mg of albumin per 24 hours on 2 of 3 urine collections) • HgbA1c – Twice a year • Microalbuminuria and eGFR– Annually http://www.youtube.com/watch?v=wlnFw9QHcHM
Admitting DiagnosisHypertensive Encephalopathy • Acute elevations in blood pressure that are associated with end-organ damage are called hypertensive crises. • Hypertensive encephalopathy refers to the neurologic symptoms that are associated with the malignant hypertensive state in a hypertensive emergency • The clinical symptoms are usually reversible with prompt initiation of therapy.
Causes of Hypertensive Encephalopathy The most common cause of hypertensive encephalopathy is untreated or poorly treated chronic hypertension. This chronic hypertension can be caused by various medical conditions such as: • Kidney Disease • Renal Vascular Hypertension • Pheochromocytoma (tumor of adrenal gland tissue) • Eclampsia (seizures in pregnant woman)
Signs and Symptoms • Headache • Altered level of conciousness • Restlessness • Nausea and projectile vomiting • Visual blurring or blindness • Drowsiness • Confusion • Seizures
Treatment Immediate control of blood pressure is extremely crucial to save patient’s life. Some of the medications that are used to manage hypertensive crisis are Esmolol, Fenoldopam, Labetolol, Nicardipine, Nitroprusside, Nifedipine, Nitroglycerin, Hydralazine, and Diuretics.
Complications of CKD • Edema and Hypertension • Anemia • Hyperkalemia • Hyperphosphatemia • Azotemia and Uremia • Metabolic Acidosis • Hyperparathyroidism • Renal Osteodystrophy
Preventing and slowing down of kidney disease • Moderate protein diet • Blood Pressure Medicines • Angiotensin Converting Enzyme (ACE) Inhibitors • Angiotensin Receptor Blockers (ARB’s) • Diuretics • Intensive Management of Blood Glucose
Medical Treatment • Dialysis • Hemodialysis • Peritoneal Dialysis Kidney Transplant Must qualify
DIALYSIS HEMODIALYSIS PERITONEAL DIALYSIS
Side Effects of Dialysis • Peritoneal Dialysis: peritonitis, hypotension, bloating and weight gain, hernias, and lack of appetite. • Hemodialysis:low blood pressure, muscle cramps, infection and clotting, itching, anxiety and depression, and sexual side effects.
General MNT for Pre-ESRD, Hemodialysis, Peritoneal Dialysis Pre-ESRD Hemodialysis Peritoneal dialysis
Rationale for Renal Diet • Fluid: Healthy kidneys maintain fluid balance but when the kidneys are damaged, it can cause fluid buildup in the body. Fluid buildup can cause shortness of breath and put a strain on the heart therefore it is important to limit fluid. • Protein and calories: Protein should be restricted during earlier stages of kidney disease to avoid the work load on kidney. However, it is advisable to eat high protein, high calorie diet during dialysis to compensate for the losses. • Sodium: Sodium influences the amount of fluid in the body and the blood pressure. Diet high in sodium can increase the thirst sensation and can cause fluid retention. • Phosphorus and calcium: Healthy kidneys remove extra phosphorus from blood. In chronic kidney disease, kidneys cannot remove phosphorus very well. Extra phosphorus causes body changes that pull calcium out of the bones, making them weak. High phosphorus and calcium levels in the blood also lead to dangerous calcium deposits in blood vessels, lungs, eyes, and heart. • Potassium: Even though potassium is important to control muscle function, high potassium can cause heart to stop beating. Therefore potassium levels in blood should be controlled.
Prescribed diet for JT At the time of the assessment patient was on Renal, dysphagia 2 diet • 2000 Kcal • 80 g Protein • No tomatoes, banana, potatoes • Limited dairy
Nutritional Assessment • Calories: 1693-1975Kcal (30-35 Kcal/Kg admit body weight, for HD) • Protein: 68-73 g (1.2-1.3 g/kg admit weight, for HD) • Fluid: Per Renal • Intake: 75% of 2000 Kcal and 80g protein diet
NCP PROBLEMS Diagnosis NI-5.8.2 Excessive carbohydrate intake related to physiological causes requiring modified carbohydrate intake, e.g., diabetes mellitus as evidenced by client history of DM and wide variations in blood glucose levels from 255-310 mg/dL and HbA1c of 7.5 Intervention RC-1.3 Collaboration/referral to other providers - Recommended average carb diet (60-75g) and possible insulin coverage for better plasma glucose control. Monitoring and Evaluation BD-1.5 Monitor glucose endocrine profile with the goal of <150mg/dL.
Nutrition Education JT’s husband believed that the renal dietitian provided sufficient education regarding renal diet. He stated Renal Education was provided on an ongoing basis and labs were consistently monitored. When offered, patient’s husband declined need for diabetes Education.
Prognosis In spite of JT’s good appetite, prognosis for her seems poor because of all the comorbidities along with ESRD. She is confused and demented. Her uncontrolled diabetes and blood pressure damaged her kidneys to the fifth stage of CKD. She is not a candidate for transplant because of her age and comorbidities (diabetes, hypertension).
Conclusion JT presented a clear picture of how common medical etiologies related to progression of CKD and ESRD are clearly intertwined Even though for years, the importance of better control of diabetes and hypertension in the prevention of CKD through MNT and nutrition education has been emphasized by health care professionals, this area seemed to be lacking in JT’s lifestyle. Barriers encountered to emphasize the need for Diabetes education included patient’s altered level of consciousness, and family member denial for further Renal diet education as well as Diabetes Education. Carbohydrate controlled diet was recommended to physician but never implemented during Hospital Stay. As a dietetic intern and future Dietitian I realize the crucial role we play as health care professionals in the prevention and slowing down of CKD, and ESRD development. JT medical status and condition depicts a clear picture of how early nutrition intervention could have delayed progression of her CKD, leading to ESRD.
Do you know? (American Diabetes Association) • The number of hours spent watching television is consistently tied to a higher risk of developing type 2 diabetes, CVD, and other major health problems (Jan. 14, 2013). • Mothers of twins and their caregivers should be prepared for a sharp increase in insulin requirements at around 14 weeks of gestation (Dec. 28, 2012). • Drinking tea may lower the risk for developing type 2 diabetes. The benefits of tea may be due to its polyphenol content, or by its influence on glucose digestion (Dec. 28, 2012).