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End Stage Renal Disease Interstitial Nephritis

End Stage Renal Disease Interstitial Nephritis. Major Case Study Krista Blackwell Sodexo Mid-Atlantic DI January 28, 2014. Objectives. Define Interstitial Nephritis Identify etiology and pathophysiology of Interstitial Nephritis

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End Stage Renal Disease Interstitial Nephritis

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  1. End Stage Renal DiseaseInterstitial Nephritis Major Case Study Krista Blackwell Sodexo Mid-Atlantic DI January 28, 2014

  2. Objectives • Define Interstitial Nephritis • Identify etiology and pathophysiology of Interstitial Nephritis • Discuss treatment and Medical Nutrition Therapy for patients with ESRD

  3. Functions of the Kidney • Elimination of waste products • BP regulation • Volume and fluid maintenance • Electrolyte balance • Acid-base balance • Ca-phos homeostasis

  4. Interstitial Nephritis • Inflammation of the spaces between the kidney tubules • Acute or chronic • Etiology • Drug induced: Antibiotics, NSAIDS • Autoimmune diseases and Systemic Diseases • Kawasaki’s Disease • Sjogren syndrome • Systemic Lupus Erythematosus • Infections: • Bacteria, Viruses (HIV) • Idiopathic • Chronic: Sickle cell disease, DM, vesicoureteral reflux

  5. Interstitial Nephritis • Pathophysiology • Not completely known • Depends on the original cause of the disease • Immune response • Inflammatory response • Infiltrates: lymphocytes, macrophages, eosinophils, plasma cells • Decrease in renal function • ESRD and Dialysis

  6. Medical Management Acute Interstitial Nephritis • Removal of drug causing condition • Steroids • Cyclophosphamide and cyclosporine Chronic Interstitial Nephritis ESRD: GFR <15 mL/min • Immunosuppressive therapy • Kidney transplant • Dialysis • Phosphate binders • Calcium Supplements • Epogen: Manage anemia • MVI: B complex, Vit C • Do not need: Vit A, inactive Vit D

  7. MNT in ESRD • Goal: Control edema and electrolyte imbalances • Sodium: 2000 mg/day • Potassium: 2000-3000 mg/day • Phosphorus: 1000-2000 mg/day • Protein: • 1.2-1.4 g/kg/day in HD • GFR <50 without dialysis: 0.6-0.8 g/kg/day • Fluid management • With HD: ~750ml + urine output

  8. Nutrition in HIV and AIDS Nutrition Recommendations: HIV Kcal: 30-35 kcal/kg IBW Protein: 1-1.5 g/kg actual weight AIDS Kcal: 35-45 kcal/kg actual weight Protein: 1.2-1.8 g/kg actual weight MVI with minerals • CD4 count <200 mm3= AIDS • Change in body composition • Loss of LBM and body cell mass • Vit B12 deficiency • Wasting • Malabsorption • Increased metabolic rate: Catabolic state • Lipoatrophy • Opportunistic Infections • TB, pneumonia, oral candidiasis

  9. Case Study: Admission • JB is a 41 year-old African American male • Presented to the ED at SGAH on December 10th, 2013 with intractable nausea and vomiting • Decreased urine output • JB was admitted to SGAH for monitoring, evaluation, and treatment of renal failure

  10. Medical Diagnoses • Acute renal failure on chronic kidney disease • Anemia • Hypocalcemia • Hyponatremia

  11. Past Medical History • Hypertension: Non compliant with medications • HIV diagnosed in 1996 • CKD: Untreated

  12. Past Medical History: Johns Hopkins • February 19, 2008: “HIV 101” • March 4, 2008: Follow-up • May 10, 2012: Scheduled kidney biopsy • June 4, 2012: Kidney biopsy, Cr 3.4 • October 22, 2012: Follow up with primary care physician. BP 160/110, Cr 3.75 • April 16, 2013: Noncompliant with medications. Wt: 72.4 kg • May 30, 2013: CD4 743, Cr 6.0 • Nov. 6, 2013: Moore Clinic

  13. Social History • Adopted • English speaking, Christian • Non-smoker, no history of smoking • No alcohol or drug use • Employment: JB works full-time at the housing authority doing office work • Lives alone in a single level home in Gaithersburg • Single, no children • Education level unknown, able to read and write

  14. Hospital Course and Consultations • Dec. 10: Admission • Dec. 11: Infectious Disease • Dec. 12: Retroperitoneal ultrasound, chest x-ray, hemodialysis catheter placement • Dec. 11, 13, 14, 17, 20: Nutrition • Dec. 13, 14, 16, 17, 20: Case Management • Dec. 13: OT & PT • Dec. 17: Guided renal biopsy: Dx. Interstitial Nephritis • Dec. 12, 13, 16, 18, 20: HD • Dec. 20: Discharge

  15. Hospital Medications

  16. Medications

  17. Anthropometric Data • Ht: 177 cm, 69.69” • Wt: • 12/10: 62 kg, 136.4 lb • 12/17: 63.4 kg, 139.48 lb • BMI: 19.79 • IBW: 75.5 kg, 166 lb • %IBW: 83% • Usual Body Weight: 74.1 kg, 163 lb • % Wt change: 16.32% wt loss over 2-3 months

  18. Initial Nutrition Assessment: Dec. 11th • Risk level: High • Diet: NPO for HD catheter placement • Summary: JB reported a 30-35 lb wt loss over the past 2-3 months. Has not vomited in 2 days. Does not want HD. HD order in chart.

  19. Laboratory Data

  20. Nutrition Prescription • Mifflin-St Jeor: REE= 1529 (1.1)(1.4)= 2355 kcal • 38 kcal/kg • Protein: 62-75 gm (1.0-1.2 g/kg) • Without HD 0.6-0.8 g/kg • Fluid: • 1860 ml (500-1000 ml + urine output)

  21. Nutrition Diagnoses • Diagnoses I: Malnutrition (severe) R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month • Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

  22. Nutrition Intervention • Goals: • Pt to meet >75% of estimated needs within 3-4 days. • Pt to maintain wt throughout LOS • Recommend Nepro BID • Will monitor need for renal diet education

  23. Monitoring and Evaluation • Monitor food and beverage intake • Monitor biochemical data: BUN, Creatinine, electrolytes, and triglycerides • Monitor weights

  24. Nutrition Reassessment: Dec. 13th • Risk Level: High • Diet: Renal Dialysis • Summary: Pt extremely lethargic, minimal responses, vomited this morning. Pt had HD cath. placed and received HD yesterday, Dec.12th. Pt still has poor po intake. Consumed 0% of breakfast.

  25. Laboratory Data: Dec. 13th

  26. Nutrition Prescription • Mifflin-St Jeor: REE= 1529 (1.1)(1.4)= 2355 kcal • 38 kcal/kg • Protein: 75-87 g • 1.2-1.4 g/kg • Fluid: 1860 mL

  27. Nutrition Diagnoses • Diagnoses I: Malnutrition R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month • Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

  28. Nutrition Reassessment: Dec. 13th • Interventions: • Goals: • Pt to meet >75% of estimated needs within 3-4 days: Not met, continue goal • Pt to maintain wt throughout LOS: Progress towards goal • Rec. increasing Nepro to TID. • Monitoring and Evaluation: • Monitor food and beverage intake • Monitor biochemical data: BUN, Creatinine, electrolytes, triglycerides • Monitor weights • Will monitor need for renal diet education

  29. Nutrition Education: Dec. 14th • RD: AN • Pt has been drinking Nepro, but not eating very much. • Pt dislikes hospital food • Provided renal diet education and printed materials from NCM • Provided “All Time Favorites” list and reviewed Renal diet options

  30. Nutrition Reassessment: Dec. 17th • Risk Level: High • Diet: NPO for kidney biopsy • Summary: N/V improved, pt still has fair po intake because he dislikes food provided, consumed about 50% of meals yesterday • Diagnoses I: Malnutrition R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month • Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

  31. Laboratory Data

  32. Nutrition Reassessment: Dec. 17th • Interventions: • Goals: • Pt to meet >75% of estimated needs within 3-4 days: Not met, progress towards goal • Pt to maintain wt throughout LOS: Progress towards goal • Pt’s renal labs WNL since starting dialysis • Recommend changing current diet to 2 gm Na restriction to increase po intake • Monitoring and Evaluation: • Monitor pt’s po intake • Monitor renal labs: BUN, Cr, K, phos, Na • Monitor triglycerides • Monitor weight trends. Requested RN to take wt on pt today since no new weights have been obtained since pt was admitted

  33. Nutrition Reassessment: Dec. 20th • Risk Level: Moderate • Diet: Low Sodium: 2 gm • Summary: Nephrologist stated that he is not concerned with JB’s K levels, but that JB needs further phosphorus diet education. Pt denied N/V, able to consume regular diet and drinking Nepro. Pt to be d/c today with dialysis 3x per week • Education: • Nephrologist requested pt receive low phosphorus diet Ed. • Provided pt with verbal explanation and written material from NCM • Pt verbalized understanding of information provided. Estimated compliance: High.

  34. Laboratory Data

  35. Laboratory Data

  36. Nutrition Diagnoses • Diagnoses I: Malnutrition R/T HIV and renal failure AEB >7.5% wt loss in 3 months and <75% intake for >1 month • Diagnoses II: Altered nutrition-related laboratory values R/T renal failure AEB elevated BUN, Cr, and phos.

  37. Nutrition Reassessment: Dec. 20th • Interventions: • Goals: • Pt to meet >75% of estimated needs within 3-4 days: Met • Pt to maintain wt throughout LOS: Met • Pt’s renal labs WNL since starting dialysis: Met • Recommend continuing 2 gm Na restriction diet. Low phosphorus. • Monitoring and Evaluation: • Monitor pt’s po intake • Monitor renal labs: BUN, Cr, K, phos, Na • Monitor triglycerides • Monitor weight trends

  38. Discharge Summary: Friday Dec. 20th • Discharge Diagnoses: • Chronic Kidney Disease-dialysis initiated • Anemia secondary to chronic kidney disease • Hypertension • Interstitial nephritis on kidney biopsy: f/u at Johns Hopkins Hospital • AIDS on antiretroviral medications. • Discharge medications: • Calcitriol, PhosLo, Darunavir, Intelence, Ferrous Sulfate, Lisinopril, Metoprolol, Raltegravir, and Norvir • Scheduled for HD at Middletown DaVita M,W,F

  39. References • Moore, Linda W. Implications for Nutrition Practice in the Mineral-Bone Disorder of Chronic Kidney Disease. American Society for Parenteral and Enteral Nutrition. Nutrition in Clinical Practice. Vol. 26 Num. 4. Aug 2011. 391-400. • Width, Mary; Reinhard, Tonia. The Clinical Dietitian’s Essential Pocket Guide. Lippincott Williams & Wilkins. 2009. • Crowe, J., Pronsky, Z. Food Medication Interactions. 17th ed. Food-Medication Interactions. 2012. • DrugBank 3.0: a comprehensive resource for 'omics' research on drugs. Knox C, Law V, Jewison T, Liu P, Ly S, Frolkis A, Pon A, Banco K, Mak C, Neveu V, Djoumbou Y, Eisner R, Guo AC, Wishart DS. Nucleic Acids Res. 2011 Jan;39(Database issue):D1035-41. 
PMID: 21059682 • MedlinePlus. Interstitial Nephritis. U.S. National Library of Medicine NIH. September 2011. Web URL: Http://www.nlm.nih.gov/medlineplus/ • Praga, Manuel., Gonzalez, Ester. Acute Interstitial Nephritis. International Society of Nephrology. March 2010. • Wyatt, Christina M., Morgello, Susan., Katz-Malamed, Rebecca., Wei, Catherine., Klotman, Mary E., Klotman, Paul E., D’Agati, Vivette D. The spectrum of kidney disease in patients with AIDS in the era of antiretroviral therapy. Kidney International. 2009. 428-434. • Boyd, Joanna K., Cheung, Chee K., Molyneux, Karen., Feehally, John., Barratt., Jonathan. An update on the pathogenesis and treatment of IgA nephrology. International Society of Nephrology. February 2012. • National Institute of Health. Chronic Kidney Disease (CKD) and Diet: Assessment, Management, and Treatment. Treating CKD Patients who are not on dialysis. National Kidney Disease Education Program. September 2011. Web URL: http://nkdep.nih.gov/resources/ckd-diet-assess-manage-treat-508.pdf • Academy of Nutrition and Dietetics. Evidence Analysis Library. Chronic Kidney Disease (CKD) Protein Intake. 2008. • British Dietetic Association. Renal Nutrition Group. Evidence Based Dietetic Guidelines Protein Requirements of Adults on Haemodialysis and Peritoneal Dialysis, BDA Renal Nutrition Group. June 2011. • Wright, Mark., Jones, Colin. Clinical Practice Guidelines. Nutrition in CKD. 5th ed. UK Renal Association. 2009-2010. • NKF K/ KDOQI Guidelines. Recommendations for Clinical Performance Measures. National Kidney Foundation. New York, NY. 2012. Web URL: www.kidney.org • Huang, Yuli., Cai, Xiaoyan., Zhang, Jianyu., Mai, Weiyi., Wang, Sheng., Hu, Yunzhao., Ren, Hao., Xu, Dingi. Prehypertension and Incidence of ESRD: A systematic Review and Meta-analysis. American Journal of Kidney Diseases. National Kidney Foundation. September 2013. • Mahan, K.., Escott-Stump, S, Raymond, J. Krause’s Food and the Nutrition Care Process. 3rd ed. Elsevier Saunders. 2012

  40. Thank You!Questions?

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